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Reorganizing to provide integrated care

May 1, 2009
by Wayne A. Maxwell, Kendall P. Alexander, and Randolph E. Ratliff
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Three agencies aim for better coordinated care in Northeast Colorado

Table. The three agencies before the mergers*






* Data for FY 2007

Year founded

1974

1957

1934

Location

Weld and Larimer Counties, Colorado

Larimer County, Colorado

Weld County, Colorado

Number of employees

95

160

177

Number of clients/year

7,500

4,308

5,100

Gross revenue

$4.5 M

$11.5 M

$12.7 M

By nature of how they were created, mental health and substance use treatment organizations often serve specific populations in specific locations. But over time agencies have realized that these service separations are artificial barriers to effective care. This is a story of how three publicly funded agencies in Northeast Colorado overcame systemic barriers to develop a fully integrated service system for individuals with a mental illness, substance use disorder, or both.

A history of separation

In Colorado, as in some other states, public funding for mental illness and substance use treatment comes through separate subdivisions of state government. Furthermore, in many parts of Colorado mental illness and substance use treatment are provided by separate provider agencies. Such was the case in Larimer and Weld Counties. Larimer Center for Mental Health (LCMH) and North Range Behavioral Health (NRBH) provided publicly funded mental healthcare in Larimer and Weld Counties, respectively, and Island Grove Regional Treatment Center (IGRTC) provided publicly funded substance use treatment in both counties. All three agencies (or their predecessors) had been providing services separately for more than 35 years.

Early forays into integration

In the 1990s, the two community mental health centers (CMHCs) and IGRTC recognized that the treatment needs of many individuals with co-occurring disorders were not being met, so they began discussing ways to provide services more effectively to this population by working together. The agencies made special efforts to establish effective co-occurring disorder programs such as “Double Trouble” groups and other co-facilitated group therapy services.

These efforts, however, had only moderate success. Service access was hindered, as many consumers referred to the “other” provider failed to appear for their scheduled appointments in separate locations across town. Therapists in the Double Trouble groups were skilled in treating the disorders they were familiar with, but they were not trained and were inexperienced in providing care for people with co-occurring disorders.

In early 2006, the three organizations recognized the advantages of providing truly integrated treatment. Consultants and staff from all three agencies became convinced that services could be provided more efficiently with better outcomes in an integrated environment.

Efforts in Larimer County. At the same time, both IGRTC and LCMH needed new office space in Larimer County. Recognizing this as an opportunity to bring their services together, the two organizations jointly purchased and renovated an office building, where they co-located staff. While this co-location provided easier service access for people with co-occurring disorders, the different chains of command and other factors prevented the level of integrated care that the two organizations envisioned.

Efforts in Weld County. In Weld County, with the full support and encouragement of their governing boards, IGRTC and NRBH began discussing how they could jointly implement fully integrated programs, including a high-fidelity Integrated Dual Disorder Treatment (IDDT) program. Both governing boards were committed to focusing on what was best for consumers and for the community. Commendably, both boards and executive staffs set aside turf and control issues.

To overcome organizational barriers related to who reported to whom, the two agencies contracted with each other for staff time, and the IDDT program had one director to whom all IDDT staff reported. This enabled the IGRTC staff reporting to an NRBH staff member to submit billing to the state for the substance use part of the IDDT program. The program director actually worked half-time for IGRTC and half-time for NRBH. Although the services adhered to the IDDT model, the program's administration was cumbersome and inefficient.

In addition, NRBH owned and operated a residential acute treatment unit (ATU), while IGRTC owned and operated a detox program and a transitional residential treatment (TRT) program for substance use. Additional discussion and analysis led to the conclusion that higher-quality services could be provided more efficiently if the detox, ATU, and TRT programs were jointly operated. Again, each agency rented space and contracted for services from the other, with one person serving as the overall program director for intensive services. This was an administrative nightmare but it worked.

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