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Game change or game over?

November 1, 2010
by Robb Enlow, LCSW
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Reengineering transforms major policy, payer changes into measurable gains

“Unprecedented change” has been the buzzword in Indiana for the past year, as the state's behavioral health authority and Medicaid program announced sweeping changes in their service delivery and reimbursement systems. Indiana's transformation initiative redefined consumer eligibility, service models, provider credentials, authorization procedures and reimbursement rates and rules-a “you name it, it's changing” scenario.

Robb enlow, lcsw
Robb Enlow, LCSW

When almost every organizational process and system is affected by new requirements, how can a provider organization prevent a game-changing scenario from becoming a game-ending event? Staff and board members at Cummins Behavioral Health Systems had to ask ourselves that question as initial analyses of the impact of Indiana's transformation initiative pointed to a 27 percent reduction in consumers who could be served; a 28 percent reduction in staff; and a 31 percent reduction in Medicaid funding-the mainstay of behavioral health financing in Indiana.

If our leadership knew one thing, it was that we needed the engagement and brainpower of all our staff, a lesson learned as we implemented high performance team principles several years ago. (See the April 2008 article, “From top-down to team-based.”)

Our first step, which started a year ago, was “information streaming.” The planned changes were comprehensive and complex, so communications required special attention from day one. A big mistake, we believe, is to use training as the primary vehicle for implementing organizational change. To truly engage front-line staff in re-engineering, we need to involve them in re-imagining. To do that, they had to be as well informed as our managers.

Next, our data managers (the direct care and support staff from each team who are specially trained in data interpretation and analysis) assumed lead roles in carrying out an impact study. They used pivot table analysis to view caseloads (by county or program) and study them according to diagnosis, demographics, levels of need, services received, and other factors critical to qualifying individuals under the new service packages that Indiana planned to implement in July 2010.

Following this analysis, the data managers shared the results with their respective teams, who were invited to consider the findings. The results were sobering: Each team considered the potential loss of consumers, services, revenue-and jobs-within their business units. (See “Pivot table analyses show possible impacts of new system.”)

To avoid the threats of malaise and inertia that can come with such unprecedented changes, we took strong action, in the form of a comprehensive organizational reengineering plan. The plan reshaped our organizational structure, redefined staff roles, adapted electronic records and technology resources, reconstructed service delivery models, developed new staff training and supports, and revised organizational policies and procedures. A later plan addition called for the closure of two offices that lacked the clinical foundation or service volume they would need to survive in the new environment. (Affected employees were offered the opportunity to transfer to other Cummins locations.)

Each team within Cummins’ six-county service area developed its own strategies for carrying out the organizational plans according to its program and constituent needs. The following describes the efforts of one such team, the staff who deliver care in Indianapolis-Marion County.

Transforming an outpatient center into a recovery-resiliency center

The new service and reimbursement model in Indiana called for a shift from traditional outpatient care to systems that promote recovery and resiliency for individuals experiencing the most acute behavioral health disorders. Service packages would be based upon two key elements: clinical assessment and level of need demonstrated.

The model proposed major reimbursement changes. Rates for group services would be cut by almost two thirds, while reimbursements for individual skill-building services would rise significantly. Payments for traditional outpatient services-rates unchanged for more than 20 years-remained the same, leaving providers little choice but to manage these services very carefully.

The new rate structure, along with new provider credentialing requirements, rendered many traditional services (partial hospitalization, for example) unfeasible, so each county team had to shift its service array to one that could accommodate consumer needs under the new reimbursement mechanism.

To transform traditional outpatient-driven care to recovery-driven care, we focused on re-engineering service systems to:

  1. Promote consumer access to rehabilitation-recovery services throughout the service process;

  2. Deliver solution-focused brief care; and

  3. Ensure clinical efficacy and efficiency to the greatest degree possible.