Nancy Cottingham, LCSW,
Horizon Behavioral Health
Central Virginia Community Services was struggling to advance its mission of treating people with substance-use disorders, mental illness and intellectual disabilities when Nancy Cottingham, LCSW, took over as CEO seven years ago. She has since maintained the focus on client-centric service but pushed the agency forward by running it like a corporation, with a new structure and renewed accountability. In fact, under her leadership, the organization was rebranded as Horizon Behavioral Health, transitioned to electronic health records, doubled its budget to $45 million, increased reserves, increased staff and integrated evidence-based best practices into care plans.
For example, as of January, providers serving public programs were required to have EHRs, but Cottingham says she drove the EHR initiative because it was the right thing to do for Horizon Behavioral Health as a business. Electronic records allow for exchange of information among providers, which fosters integrated care. At the same time, such systems can be used to track outcomes more effectively. She says the field in general has been slow to adopt EHRs, but the Affordable Care Act has forced the issue to push providers to where they need to be.
However, the EHR implementation process for Horizon Behavioral Health didn’t go as smoothly as she would have liked.
“Part of leadership is being willing to make mistakes,” she says. “You have to make a decision when something isn’t working to make a change.”
EHR platforms are relatively new in behavioral healthcare, so anticipating how the features and functions would work in real-world application was difficult, she says. For Horizon to satisfy reporting requirements, the organization had to be able to deliver specific data points to public programs and other payers collected through its EHR. Therefore, its system had to be nimble enough to gather and manage the data. Because the reporting wasn’t moving as planned, Cottingham says Horizon is changing its EHR system this year to better manage its state reporting needs. She recommends that leaders take ample time to complete their due diligence when implementing IT systems.
“Ask your colleagues in other organizations about their experiences,” she says. “You really can’t have too much information.”
As behavioral healthcare makes a paradigm shift from process-driven workflows to outcomes-driven business operations, Cottingham says, providers must focus on measuring results and using the measurements to improve. Organizations can view almost anything as measureable and examine it in the context of outcomes. The key is to think about what constitutes a point of “success,” she says. For example, in a situation where a child improves his grades, misses school less often or cries fewer times per week as treatment progresses, each of those observable points can be recorded as a measured outcome.
“These are all things that are very concrete if you make them concrete and ask the right questions,” she says. “Our field has undergone a transformation in this respect, and it’s well overdue. Honestly, we can measure things, and we should have been doing this all along. We always told the public, ‘trust us, this works,’ but not everything does work.”
Cottingham recommends using online resources such as SAMHSA to implement best practices that are based on evidence. She also believes providers can set goals and translate them into objectives, even though some outcomes are much more difficult to measure.
“In our organization, we always start with the evidence-based practices,” she says.
Outcomes measures are especially critical for the chronically mentally ill that require ongoing treatment to simply live better even if there isn’t necessarily a cure. Pay attention to what works and document results.
“Just because you love doing a particular technique, if it’s not working, it’s not useful, and you need to move on,” she says. “You need to focus on what really is effective and not what you thought would be effective.”
Even with strong evidence-based practices, cost effectiveness is always the key to sustaining any business, no matter the size. Horizon has 25 locations, and last year provided 7,471 people clinical services, and an additional 2,940 received preventive service.
“Part of being cost effective is not spending money you don’t need to spend, but also not being stupid about not spending money when you need it,” she says.
For example, every behavioral health provider must have the appropriate capabilities to deliver needed services, not just in terms of programs, but also in terms of staff care-delivery skills, operational efficiency, consistent streamlined processes and management support. Too many leaders expect to do more and more with less, she says, but there’s a limit to how far the efficiencies can stretch.
Although Cottingham retired from Horizon Behavioral Healthcare in July, she is genuinely hopeful about the future of behavioral healthcare.
“We get a lot of criticism when things don’t go well, but I’m really proud of the field, and I think we’ve stepped up and tried to do our very best with the science we have at this point,” she says.