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Improving services by holding hands, not pointing fingers: service agencies in Colorado Springs had to overcome differences to address a detox bed crisis.

Imagine a community with a social detox center decreasing its number of beds, along with facing gaps in linkages from detox to outpatient treatment because of funding cuts. This results in overcrowded and misused emergency rooms filled with intoxicated people, and patients leave before being seen. Law-enforcement needs increase to respond to inebriated people on the streets. Community agencies become increasingly frustrated and mistrustful of each other. The community essentially is in crisis because of substance abuse issues.

That was the community climate in Colorado Springs in 2001. Pikes Peak Mental Health (PPMH) decreased its detox bed availability because of funding cuts. Yet throughout this crisis, much community dialogue occurred and a new model was born.

For behavioral health agencies to transform into quality-leading community players, new approaches and tools for building interagency trust and overcoming embroiled politics are a must. But how do you do this when behavioral health is misunderstood, mistrusted, and often viewed as an afterthought? What follows is the approach taken in Colorado Springs and the lessons we learned.

The Problem

In 2001, the PPMH board directed the CEO and senior staff to "fix the detox problem." Programming had been funded partially by the state with the expectation that communities also would provide funding. At that time, 60% of the Detoxification Center's financial support came from the Colorado Division of Alcohol and Drug Abuse, 6% from the local county commissioners, 11% from the city, and 23% from the center's humanitarian foundation, a grants- and resource-related division of the community mental health center.

Funding was in jeopardy, and the board did not want to increase dependence on PPMH's foundation dollars because detox operations were accumulating net losses of close to $1 million per annum. At the board's direction, the CEO and COO met with leaders at community agencies, city government, and county government to address the urgent funding need and announce the detox bed decrease. They were skeptical that PPMH really needed to decrease beds so significantly, and they questioned PPMH's motives. There were many questions about PPMH's finances and unsolicited media attention, all with a flavor of mistrust. The barriers in obtaining a financial commitment from the proposed collaboration seemed to stem from two main points:

* strong value judgments about helping the substance abuse population, opting for the "drunk tank" alternative (a holding area with no treatment) as opposed to a therapeutic treatment approach; and

* a belief in the community that PPMH was fiscally responsible for substance abuse care for the community as a whole, and allocated dollars should be managed more effectively.

Without additional financial commitments, PPMH had to significantly reduce capacity from 24 to 8 detox beds in June 2001 and change programming from a modified medical detox program to a social detox program. This resulted in ER overcrowding, more law-enforcement responses to inebriated people on the streets, and business leaders' complaining about intoxicated people downtown. Everyone wanted to know why PPMH had decreased bed availability--and how PPMH was going to solve the problem.

Solutions

Stage one: Bringing the community onboard. PPMH recognized it had the community's attention and hired a respected local consultant to initiate a task force to clear the air and develop community solutions. PPMH invited all community stakeholders, and many did participate. Initially, many questions were raised about PPMH's finances and detox services.

Each group or agency evaluated the problem as it related to its specific situation and offered correlating solutions. For example, law enforcement wanted a drunk tank without treatment components, and hospitals wanted intoxicated individuals removed from their ERs. The task force often focused on each agency's funding commitments, and finding solutions was made more difficult because of three factors:

* an overall mistrust of the mental health center and a belief that the task force's initiation was self-serving;

* agencies' blaming each other for the problem; and

* weak communication and undeveloped relationships across the task force.

By this point we had learned several lessons:

* PPMH had to be transparent and willing to open up and expose the organization to build trust. Thus, PPMH shared its detox financial information with the community, and this went far in easing mistrust.

* Solid data were critical in addressing mistrust and facilitating communication, and PPMH shared its client numbers and outcomes data.

* Mission had to drive staff behavior. The CEO was continuously visible and delivering the message. This helped anxious staff live through the community's scrutiny and delivered a consistent message about PPMH's interest.

Stage two: Identifying solutions. To move the task force toward decisions and solutions, a smaller group of decision makers was formed, comprising two hospital CEOs, a local psychiatric facility's senior administrator (which also provided detox services), the assistant director of county government, a city intergovernmental liaison, PPMH's CEO and COO, and the deputy police chief.

The new task force brought in an independent consultant to facilitate planning. A local hospital, Penrose-St. Francis, secured a grant for a planning study to identify and develop a long-term, financially viable continuum of care for detox services. Penrose also offered a staff member to serve as group facilitator.

The task force needed to identify:

* the community's needs specific to a continuum of care for substance abuse;

* a care model to meet all service users' needs;

* financial options; and

* methods to secure fiscal commitment.

The outside consultant's objectivity further dissipated mistrust and encouraged healthy collaboration, and group facilitation by a non-PPMH staff member aided the group's progress. The consultant conducted a comprehensive environmental scan, analyzed the existing services, projected community needs, and evaluated service-delivery models. To identify strengths and weaknesses of substance abuse services/treatments, including delineating barriers and opportunities, the consultant conducted a community-wide survey of 50 stakeholder groupings, which included community agencies, providers, the recovering community, and the public.

In January 2003, the task force agreed on a model based on input from 40 community agencies, results from the community stakeholder survey, and an analysis of successful programs. The model included developing a modified medical detox program designed to serve medically compromised individuals, as well as treating those in need of a social detox setting. The model also included a continuum of care with intensive outpatient programming, aftercare/outpatient care for the underinsured individual, and transitional living using a recovery house model.

The task force developed an implementation plan that detailed the staffing pattern, expected costs, and shared outcomes. A subcommittee was appointed to handle specifics about the recovery house and community education. The main task force tackled funding.

A historical review of detox service utilization by each of the two hospitals and from city and county law enforcement provided a baseline for funding. The task force decided that each referral source would fund services based on their historical utilization pattern.

Stage three: Implementing the new model. The new model was in place by April 2003. A Detox Coordinating Council, comprising funding source representatives, replaced the task force.

The council meets monthly and reviews a 20-page outcomes report provided by PPMH. By using a medical protocol, the detox center and hospitals now work together to stabilize and treat intoxicated people. Police and ambulance personnel conduct field evaluations and bypass hospitals, taking intoxicated people directly to PPMH. In addition, the council initiated a community-wide media campaign on substance abuse.

Results

Data showed evidence of beneficial outcomes for community agencies, as well as substance abusing clients (table). The results of the new model at PPMH are:

* an 83% increased capacity because of reduced client stays, allowing more patients to receive treatment;

* a 27% increase in access to services;

* a 24% increase in customer satisfaction; and

* an approximately 29% reduction in client readmission.

One local hospital reports:

* a 13% decrease in ER patient visits with an alcohol or drug diagnosis;

* a 46% decrease in time for an ER patient to get to a bed; and

* a 63% decrease in patients leaving the ER without being seen by a physician.

Both hospitals found a $200,000 reduction in hospital use associated with nine of the most chronic substance abusers, who are now sober.

Important Lessons

We learned several important lessons that other behavioral health organizations could find useful when in similar situations:

Address community complacency. The community had little appreciation for treatment and its effectiveness, as well as a belief that PPMH, through its funding or mission, was somehow responsible to solve all of a substance abuser's problems. We created community awareness regarding the discrepancies between adequate care, the complex interactions of substance abuse variables, and the impacts on the community to ensure that the community, not an agency, owned the issue.

Be transparent. Be willing to open up and expose your organization. This is a building block of trust. PPMH shared its detox financial information with the community, and this went far in easing mistrust.

Provide solid data. Having solid data is critical in addressing mistrust and facilitating communication. PPMH shared its client numbers and outcomes data. This also eased mistrust and fostered communication.

Adhere to your mission. Mission must drive staffbehavior. These were anxious times for staff, and a reconnection with mission proved key in living through this difficult period. It is especially important for the CEO to visibly and credibly deliver the message.

Let go of control. When collaborating, it is important to let go of control so as not to be viewed as self-serving. The outside consultant's objectivity decreased mistrust and encouraged healthy collaboration. Group facilitation by a non-PPMH staff person aided the group's progress.

Build a clinical continuum. A robust clinical continuum linked to expected outcomes is critical. Develop the continuum in collaboration with community stakeholders.

Identify shared outcomes. Identify shared outcomes across systems to aid buy-in.

Educate the community. Education on behavioral health issues is critical to ensure community buy-in. Sharing expertise about behavioral health issues, rather than an agency's performance, provides value to the community and is less likely to be viewed as self-serving. Our efforts were recognized not only locally, but nationally: Pikes Peak Mental Health Center won the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) 2005 Ernest Amory Codman Award in the Behavioral Health Care category.

Conclusion

The process and results outlined in this article are a testament to the hope of building, rebuilding, and maintaining community relationships that benefit individuals who are often forgotten, are misunderstood, or face discrimination. The successful collaboration has instilled in the community the value of active and therapeutic treatment for our substance-abusing population while establishing an accountability model conducive to continuous improvement.

Sharon Raggio, MBA, LPC, LMFT, is COO of Pikes Peak Integrated Solutions, a member of Pikes Peak Behavioral Health Group. Sonia Jackson, BSW, CAC III, is Director of Acute Services, Lighthouse, Pikes Peak Mental Health Center, a member of Pikes Peak Behavioral Health Group. Matthew Sullivan, BA, MA, EdS, is Director of Operations and Corporate Compliance at Pikes Peak Mental Health Center.

The subject of this article will be presented by the authors at the National Council for Community Behavioral Healthcare annual conference in April in Orlando.

To send comments to the authors and editors, e-mail raggio0306@behavioral.net.

BY SHARON RAGGIO, MBA, LPC, LMFT; SONIA JACKSON, BSW, CAC III; AND MATTHEW SULLIVAN, BA, MA, EDS
TABLE. Results of the community collaborative

 Observed change (from Apr. Significance
Indicator 2003 to Dec. 2004) level

Law-enforcement referrals 69% decrease in referrals p<0.05
Capacity 83% increase in capacity p<0.01
Client satisfaction 24% increase in satisfaction p<0.37
Recidivism* 23% decrease in recidivism p<0.022
Referrals to emergency rooms 13% decrease in referrals p<0.059
Access to care 27% increase in access p<0.48

*Recidivism is defined as two or more detox encounters from April 2003
to December 2004.
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Title Annotation:COMMUNITY COLLABORATION
Author:Raggio, Sharon; Jackson, Sonia; Sullivan, Matthew
Publication:Behavioral Healthcare
Date:Mar 1, 2006
Words:1944
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