The afternoon meeting in July 2004 was an informal get-together between two executive directors, who often met to discuss issues that affected both of their organizations in Alaska's central Kenai Peninsula. No one would have predicted that a seed planted that day—to build a facility that houses both a community mental health center and a community health center—would become reality just three years later. Even more surprising has been the enthusiasm of both organizations' boards to consider an even more integrated approach to care.
The community mental health organization is Central Peninsula Counseling Services (CPCS), which recently celebrated its 30th anniversary. With 100 employees and a $5 million annual budget, CPCS provides a comprehensive array of clinical and rehabilitation services for seriously emotionally disturbed children and severely mentally ill adults, operates an adult day center for the frail and elderly, and provides around-the-clock psychiatric emergency services.
Central Peninsula Health Centers (CPHC) is a five-year-old federally qualified health center with a $4 million budget and more than 50 employees. CPHC operates Cottonwood Health Center, a primary care clinic, and Aspen Dental Clinic, providing services regardless of patients' ability to pay. The organization particularly focuses on prevention and chronic disease management.
Both CPCS and CPHC serve vulnerable and economically disadvantaged residents of the central Kenai Peninsula in south-central Alaska, a popular tourist destination for outdoor enthusiasts. The central Kenai Peninsula is a large rural area with almost 33,000 residents. Much of the employment is seasonal, unemployment rates are relatively high, and roughly 20% of the population lacks health insurance of any kind. Health status statistics for the area reveal relatively high rates of chronic health conditions including mental illness.
Historically the relationship between CPCS and CPHC was friendly but limited. In 2004, CPHC secured a grant to provide behavioral health screening and brief intervention services to its medical patients and subcontracted with CPCS to provide these services in the primary care setting. This initial integration of staff and services, albeit relatively modest in scope, served as the foundation for the colocation discussions that followed.
For CPCS, colocating with a community health center will provide benefits for both consumers and the organization. With youth and adult mental health programs currently split between two communities 11 miles apart, it is challenging to manage and coordinate services. Families with both child and adult consumers must travel to two separate locations. Psychiatric services are offered primarily at one site, thus limiting access. Maintaining two facilities has increased operational expenses through use of courier services and duplication of support staff, utilities, transportation, and building maintenance costs, which are particularly challenging in the current funding environment.
For CPHC, the new building represents an opportunity to create a healthcare setting optimally responsive to providers' and patients' needs. CPHC currently operates in a rented facility with neither adequate space nor a functional design, and it cannot meet the growing organization's needs.
For both organizations colocation will provide economies of scale and operating efficiencies through shared maintenance, phone system, information technology, and utility costs. We also are considering sharing administrative functions, such as human resources or finance. Yet regardless of the cost savings and increased efficiencies, the most compelling argument for colocation is that it will create the opportunity for consumers to receive holistic, coordinated care.
A recent study revealed that persons with serious mental illnesses die 25 years younger than the general population, with much of the disparity attributed to inadequate medical care of chronic physical and mental disabilities.1 This study clearly underscores the need for integrating primary care and behavioral health services. Although some of CPCS's clients are being seen by CPHC providers, many do not have a medical home. The organizations' colocation will increase the likelihood that CPCS's consumers will access CPHC's services and vice versa. Colocation also will create an opportunity for consultation among providers and the development of more collaborative treatment protocols.
The New Facility
Fund-raising for the new building has been a joint effort, and has rapidly increased the organizations' sense of partnership. Thanks to CPHC's early leadership, a strong base of funding has been secured. To date, commitments to cover more than 60% of the $10 million project have been provided by the Denali Commission, Rasmuson Foundation, Alaska legislature, Alaska Mental Health Trust Authority, Salomon Foundation, and personal pledges from board members and staff, while decisions on other grant requests are pending.
CPHC is the project's developer and has had primary responsibility for the building's planning, design, and financing. We are using a condominium approach to the building's ownership to assure that each organization has a voice in decision making. Groundbreaking for the new facility, Peninsula Community Health Center (PCHC), was June 16, 2006, and the projected opening date is November 1. Kluge & Associates designed the building.
The 31,000-square-foot facility will house primary care services on the first floor; the second floor will house behavioral health services and administrative offices for both CPCS and CPHC (figure 1). Both organizations' staff and board members were involved in spatial planning and interior design. In keeping with the spirit of partnership that has defined this project, the new building will offer shared multipurpose rooms for board and community meetings, as well as space designated for public health immunizations and specialized services provided by other community organizations.
While the colocation project has generated both enthusiasm and out-of-the-box thinking, the process has its challenges. Bringing together two organizational cultures with similar but separate missions creates a variety of stressors. For CPCS, simply having staff under one roof represents a significant change. When the internal consolidation is coupled with the colocation with primary care, staff likely will need to make considerable adjustments. Also, some mental health consumers have opposed moving staff and programs to a different location.
The most important challenge is determining the ultimate degree of integration between the two organizations, which is a work-in-progress aggressively being addressed by both boards and management teams. To help address this challenge, CPCS sought the assistance of the National Council for Community Behavioral Healthcare and one of its consultants, Kathleen Reynolds, MSW, ACSW, who specializes in primary/behavioral healthcare integration (sidebar).
Right now, the boards can be viewed as “dating” as they form work teams addressing integration issues relating to clinical services, governance, and administration/operations. Our organizations will be “engaged” when PCHC opens in November and potentially “married” (i.e., merged) a year after that. Whether our organizations eventually merge is not so much the goal as is conducting the due diligence to make the right decision, building trust among the boards and staff and, most importantly, making organizational decisions with the consumer as the priority.
Rae S. Sanders is Director of Community Services at Central Peninsula Counseling, Services in Kenai, Alaska.
Ted Schiffman is Executive Director of Central Peninsula Counseling Services.
Stan Steadman is Executive Director of Central Peninsula Health Centers in Kenai, Alaska.
- COLTON CW, MANDERSCHEID RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis 2006; 3 (2). Available at: www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.
The Peninsula Community Health Center is expected to open November 1. Illustration by Kluge & Associates
Meeting the Fundamentals for Success
by Kathleen Reynolds, MSW, ACSW
In the past several years, three landmark reports have called for public mental health systems to become engaged in integrated healthcare initiatives. The report of the President's New Freedom Commission on Mental Health, the Institute of Medicine's Improving the Quality of Health Care for Mental and Substance Use Conditions report, and the recent National Association of State Mental Health Program Directors report, Morbidity and Mortality in People with Serious Mental Illness, all speak to the profound need for integrating behavioral health and primary care services for persons with severe and persistent mental illness. Central Peninsula Counseling Services (CPCS) and Central Peninsula Health Centers (CPHC) are answering this call. Their partnership promises to be effective because it is founded on five fundamental principles shared by any successful organization:
Shared vision. Their vision is embraced by all levels of both organizations. The boards of directors, senior administrative staff, and line staff have been engaged in the discussions. Functional implementation groups across all levels of the organizations are working to make the vision a reality.
Consumer focus. Partnerships such as this one often fail because of turf wars. But CPCS and CPHC are focused on what makes sense for those they serve—their consumers. Keeping the consumer at the center of decision making will lessen the tendency to argue over turf.
Community focus. CPCS and CPHC understand the community, as well as the challenges and opportunities available to the partnership. A brief SWOT (strengths, weaknesses, opportunities, and threats) analysis completed during my consultation clearly pointed out that they understood that their community would be improved by the partnership. Key barriers were viewed as opportunities rather than as reasons to not proceed.
Openness to change. It was clear from my first phone call with Rae Sanders that the leadership was open to change. When I suggested they consider integration instead of just colocation in the new building, the senior leadership team embraced the idea. Board members and line staff could see the potential. Line staff immediately saw how the partnership could benefit children. Billing staff quickly recognized the potential for savings and revenue enhancement.
Leadership. Leaders embraced the shared vision and immediately engaged in disseminating it to the organizations and community. Key governmental leaders were brought in early in the process. The board chairs, executive directors, and key senior staff stepped forward and developed action plans that allowed adequate time to address any potential barriers.
It was a pleasure to work with the folks in Kenai. I wish them the best of luck, although I don’t think they’ll need it. They are doing all the right things that should lead to success.
Kathleen Reynolds, MSW, ACSW, is the Director of the Washtenaw Community Health Organization in Michigan, and she has more than 25 years of experience in the mental health and substance abuse field. For the past seven years, her primary emphasis has been on developing integrated models for Medicaid and indigent consumers.