Creating an Integrated Healthcare Facility: The Challenges, Missteps and Solutions
Bern Heath, Ph.D., CEO, Axis Health System, November 2014
In November of 2006, the Board of Directors of Southwest Colorado Mental Health Center, Inc. made the strategic decision to transform our traditional community mental health center to an integrated healthcare system. This paper follows that transformation and in the process addresses the challenges, missteps and solutions developed to accomplish the transformation. It is hoped that the experiences presented here will inform other such efforts.
Our strategy to transform our organization began by embedding1 behavioral healthcare in a variety of primary care settings with the expectation that care in these settings would become increasingly integrated. While this embedding did result in demonstrably improved health outcomes, it did not meet the expectations of increased integration and evolving practices. These results led the Board and administration, in February of 2009, to move from embedding in existing primary care practices to establishing our own fully integrated clinic in Cortez, Colorado.
In April of 2010, Southwest Colorado Mental Health Center, Inc. adopted a new name and Mission Statement to support the transformation to integrated healthcare:
Axis Health System will make a meaningful difference in the health of southwest Colorado residents by integrating all aspects of healthcare and treating the whole person.
The new name and mission marked a commitment to leave behind our identity as a traditional community mental health center - though not to abandon the commitment to serve the substance use and mental health needs of our community which we believed would be better served in the context of a transformed and integrated primary healthcare system. This was not a vision of a behavioral health agency providing primary care. Rather our vision was analogous to baking a cake where antecedent parts of eggs, sugar, flour, and other ingredients (i.e., mental health, primary care, substance use, wellness, etc.) no longer exist separately but as a single transformed whole…in our case, whole person healthcare.
In January of 2012, Cortez Integrated Healthcare (CIH) was completed and began operation.
In the Beginning…
We prepared for the opening of CIH by realigning our staff. We had spent six years developing the conceptual model and two years designing and constructing the facility. We conveyed our concept in multiple staff meetings, through individual supervision and in regular updates in the staff newsletter.
We moved out staff that were not on the right bus2 for this transformation, hired the best new staff we could find and oriented them to our vision and concept. Our preparation constituted an extended and substantial effort that followed a traditional and time tested process for the start-up of new programs…. and therein lay the problem.
After one year of operation, our clinic had improved the health of our patients in many ways. The integration of care occurred intermittently and at various levels – but we had not yet achieved the vision of consistent and full integration of care. The process with which we began failed to create both a stable and self-evolving culture of integration and a team treatment model needed to deliver the highest levels3 of integrated healthcare. We had not overcome the cultures of separate professional disciplines and we had not established a consistent, knowledgeable and engaged leadership at the facility.
With this failure we came to the realization that traditional, incremental processes can be used effectively to create a new program but are insufficient to transform an organization. To “bake our cake” we needed to change at more fundamental conceptual, structural, and operational levels.
Since the construction of CIH we have provided over 40 tours to more than 200 people – demonstrating how we are transforming primary healthcare. We found to our surprise that though people expressed to us that they really understood what we were doing, they actually did not. What they saw and heard was filtered through their expectation and experience as largely traditional primary care in closer relationship to (but still separate from) behavioral health. It takes a great deal of time and exposure to work past and change the internal filters of those interested in understanding how fundamentally we are changing healthcare conceptually and in its delivery.
In order to overcome this lack of understanding internally (with our own staff), we created Axis Integration College. The College was initially structured around 12 course modules with 21 hours of instruction over 3 intense days of training. Instruction included didactic presentations, discussions, group exercises and hands-on training. While we have maintained the variety of instructional techniques, the labor intensiveness of this structure and loss of staff availability for 3 entire days multiplied by a staff size approaching 200 reduced the feasibility of this structure. We have since restructured the college, distilling the content down to 8 course modules focusing on the essentials of practice, over two days. This has proved both more manageable and practical.
The College remains a time consuming and labor intensive solution to the need for a deeper staff understanding of a transformed, integrated healthcare system. It is also significantly undermined by staff turnover (which is always higher when an organization is transforming). Once a critical mass of staff who truly understand the concept of integration is achieved, and staff are better prepared in their professional training programs, the need for an internal structure such as the College diminishes. Existing staff will train new staff and an e-learning structure may well be sufficient to maintain the necessary level of understanding. Until then, the investment in a College like structure appears to be needed.
Champions. Axis Integration College provided the foundation for a conceptual understanding, practice change and team that we needed, but over time and with staff changes that foundation erodes. To inoculate against this erosion, and indeed to build upon the gains of the College, we rely upon two levels of leadership or “Champions”. We have established both a CIH Director (the formal leader who is an active member of Axis’ executive leadership team), and change zealots4 (the informal internal staff leaders). Working in tandem, these two leadership structures keep the clinic focused on the goals, values and outcomes while encouraging and supporting innovation and practice change.
Practice Change. Changing how we practice healthcare provided insight to our process that we had not expected. At the beginning we thought that the difficult part would be in conceptualizing the changes to care that we needed to make. As we progressed, we found that it was not the conceptualization that presented the greatest challenge, but the design (administrative and clinical structures) that was more difficult. Yet as implementation proceeded, we have found that the change in culture – how we interact and how we practice – has been the most difficult challenge we have faced.
The embedded settings improved health outcomes, but when it came to changing the primary care practice to become more integrated, the practices were not interested. This is a critical point and is best captured in a quote from Pam Wise Romero, Ph.D., the Axis Chief Clinical Officer: “Everyone wants to do integrated care until they realize that they have to change how they practice.” When they realize they have to change how they practice, they try to change the concept of integration to accommodate their current practice instead.
While it is easy to see the need for practice change by others, the need for change in oneself is less evident. Integrated care bends the cost curve for healthcare by generating better health outcomes. This, then, requires us to align our financial incentives away from fee-for-service and the measurement of units of service (which does not support higher levels of integration5) and instead measure the impact of our services (outcome)6. This not only requires funders to change how they practice, it requires us, as service organizations, to move from encounter/unit of service based measurement7 to population based health outcomes. Outcomes are a more meaningful accountability mechanism for funders and can serve as a vehicle to determine productivity by site – challenging, but necessary. We, as administrators must change our practices as well.
In the article Leading Disruptive Innovation by Soren Kaplan (Innovation, July/August 2012) he is talking about transformation when he says, “…there’s simply no way to build tomorrow’s essential organizational capabilities – resilience, innovation and employee engagement – atop the scaffolding of 20th century management principles.” Kaplan, referencing Steve Jobs and Apple, goes on to say, “Asking the market what it wanted would have been fruitless since consumers didn’t know what they were missing until they were given it by the company…Disruptive innovations come from people and organizations who ‘innovate for themselves’ because they want to make a difference for others. Leading through disruption requires an agile mind that appreciates ambiguity. Disruptive innovators know that uncertainty contains as much opportunity as it does risk.” While Kaplan is focused on the qualities of management, the same level of disruptive innovation is required of service (clinical and administrative) staff as well.
Team Function. Implicit in the above discussion is that practice change requires an individual commitment. This is a necessary, but not a sufficient condition for practice change to impact the entire system/culture. For practice change to drive the evolution of integrated healthcare we have found that it needs both personal commitment and the power of teams8. We are using two kinds of teams to drive the evolution of integration and improved health outcomes at our two integrated clinics.
Service delivery at CIH and La Plata Integrated Healthcare (LPIH)9 is built on the structure of Care Teams. Our concept of care teams is different from the traditional multidisciplinary team in that it is not led by a physician or any assigned discipline. With the cultural “team” structure and institutional cross-training, all participants10 are expected to contribute within and outside of their disciplines in the best interest of patient care. Patients are assigned teams in which they actively participate and the entire team is equally responsible for all aspects of the patient’s health. The problem is that assigning staff to a team that “cares” does not a care team make. Care teams must be high functioning – staff must carry their weight as there is no place to hide, members must contribute actively while checking their egos at the door, and team members must collectively maintain a laser like focus on what generates and sustains the best health outcomes for the patient/partner in the team.
Clinical practice change relies in large measure on administrative practice change. Documentation, patient flow, access, accountability and compliance each have their administrative structures which too often obstruct the best patient care in service to their individual purposes. In order to align administrative structures to best support clinical outcome, we have established teams to re-design and modify our administrative infrastructure11 - that is, to change our practice. This should not be confused with a democratic process which is notorious for its inefficiency. Instead, team members with interests in particular problems are empowered and expected to lead the organization’s solutions.
Building high functioning teams is challenged by the different backgrounds and styles of staff and frustrated by changing personnel. Having established the shared vision and values through the College, we address the challenge through the group process of team building and reference to Patrick Lencioni’s The Five Dysfunctions of a Team (National Council Magazine, 2011, Issue 1); Absence of Trust, Fear of Conflict, Lack of Commitment, Avoidance of Accountability, and Inattention to Results. We address the frustration of changing personnel by relying on the team process to acculturate new team members. By taking advantage of the power of high functioning teams we institutionalize practice change and create a self-evolving integrated operation.
In addition to addressing conceptual (understanding) and operational (care delivery) issues we have become aware of two structural issues that have proven to be barriers to integration and a successful transformational process.
Split Care. The first barrier became apparent when we brought our original base of behavioral health patients into an integrated health setting. In doing so, a portion of our behavioral health population wanted to receive their behavioral health care from us, while preserving their primary care relationship with another provider. As understandable as this is, it creates split and fragmented care which has proved inconsistent with our concept of population based12, integrated, whole-person care. Being population based we care for the entire population in an integrated manner not some of the population in an integrated manner and some without regard for all aspects of care (e.g., behavioral health only). Splitting care systems undermines the integration of care for patients and the establishment of an integrated flow at the facility.
At CIH we are overcoming this by establishing a separate care pod13 for those patients who are seeking behavioral health care only and receiving primary care elsewhere. Thus, we operate an un-integrated clinic (much more of a traditional mental health center) within our integrated clinic. It is important to note that this structure, seemingly inconsistent with our model and the paragraph above, has two critical features; (1) we believe it is a necessary step in the transition process to integrated (whole-person) care and (2) over the course of time we will reduce to 0 the number of patients in this pod, thus this is a transitional and temporary strategy.
As Axis has been awarded a Federal 330 Grant (similar to Cherokee Health Systems in Tennessee) we established a new, integrated, Community Health Center clinic in our most populated county and the community housing our current base of operations. Here, our solution is a little different. Instead of a clinic within a clinic, we retained our more traditional behavioral health operation in one site for those clients that want to keep their existing primary care relationship, and receive behavioral health services only from us. We established the Community Health Center in a separate site as an integrated clinic for those without existing primary care relationships and those who wish to move their whole care to Axis.
Differing Scales. In many ways, building an integrated health system from the ground up, with no antecedent identity or commitment to a single population, is much easier. Transforming, moving from being a traditional mental health center to becoming an integrated health system, presented challenges in moving our patients. As a behavioral health provider we are the primary game in town, providing about 80% of the community’s behavioral health care and almost all of its emergency and inpatient behavioral health care. As an integrated primary care health system, we provide about 10% of the community’s primary care. This disproportion also challenges the structure of integrated care. In order to care for 80% of the population with behavioral health needs and 10% of the population with primary care needs, we can certainly design our care teams with proportional staff expertise…but we have found that when the volume of medical providers drops below 2 FTE, integration cannot be sustained. There must be a critical mass of both staff with behavioral health expertise and with medical expertise to support our integrated health model. We can hope for a future with staff trained to have far less of a gap between current medical and behavioral training, but for now we need to work within the constraints that exist.
If an organization is to transform to increasingly integrated levels of care it will be challenged by the concept and process of that change. In the same way we cannot fix a typewriter enough to make it a computer14, we cannot fix a traditional fee-for-service community mental health center enough to make it a population based, integrated health system. While transformative change must be incremental on the one hand (so it does not overburden the system in the process), it must also embrace practice change principles.
In our transformation to an integrated health system and our establishment of CIH, a transformed, integrated, primary care clinic aspiring to Level 6 integration, we have learned a number of important lessons.
Lesson 1 – Embedding
While embedding behavioral healthcare in other organizations’ primary care settings resulted in demonstrably improved health outcomes the expectation of increased integration and evolving practices were not met.
Lesson 2 – Traditional Program Development does not Transform
Transformation is a process that requires a far greater commitment of resources and broader effort than the establishment of new programs.
Lesson 3 – Conceptual Change
Transforming to a new concept of integrated care will result in staff filtering the concept through their expectations and experience thinking that they understand before coming to a true understanding. Organizations must recognize this process and be prepared to commit time and resources through a variety of mechanisms to ensure staff reach a level of understanding that will result in truly integrated care.
Lesson 4 – Champions
To move the understanding to practice, it takes two levels of leadership or ‘Champions”: the formal organizational leaders (with management titles) and change zealots (the informal internal staff leaders). Working in tandem, these two leadership structures keep the organization focused on the goals and values while encouraging and supporting innovation and practice change necessary for the evolution of the practice.
Lesson 5 – Practice Change
“Everyone wants to do integrated care until they realize that they have to change how they practice.” When they realize they have to change how they practice, they try to change the concept of integration to accommodate their current practice instead. We have found that changing how each individual (administrative and clinical) practices and changing how the team practices as a team has been the most difficult challenge we have faced. Without a commitment to practice change and structures to support that change (restructured decision mechanisms and incentives) transformation and the evolution of integrated care will fall well short of its potential.
Lesson 6 – Team Building
For practice change to drive the evolution of integrated healthcare we have found that it needs both personal commitment and the power of teams. Service delivery in our integrated settings is built on the structure of Care Teams. The problem is that assigning staff to a team that “cares” does not a care team make. Care teams must be high functioning with a laser like focus on what generates and sustains the best health outcomes for the patient/partner in the team. In order to align administrative structures to best support clinical outcome, we have also established teams to re-design and modify our administrative infrastructure - that is, to change our practice. Building high functioning teams is challenged by the different backgrounds and styles of staff and frustrated by changing personnel.
Lesson 7 – Split Care
In moving from a community mental health system to a new integrated health system a segment of patients will want to continue to have their behavioral health services with you but preserve their primary care relationship with another provider. Splitting care systems in this way preserves service fragmentation, undermines the integration of care and impedes an integrated flow of services. This can be overcome by transitional and temporary strategies of embedding an un-integrated clinic within a clinic or by temporarily maintaining an un-integrated mental health center in one site and an integrated clinic (serving the full range of health needs) in another site.
Lesson 8 – Differing Scales
Establishing a new system on the foundation of an old one brings with it a challenge of unbalanced proportional coverage. In our case our behavioral health base population constituted 80% of the community capacity, but as a transformed integrated primary care system we will be providing only about 20% of the community capacity. This means that we need to balance our staff proportional to the needs of our community. In so doing, we have learned that there needs to be a critical mass (i.e., a minimum) of 2 FTE medical providers (physicians, nurse practitioners) within an integrated clinic to support integrated care.