This Article Extract Reprint (PDF) Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Meehan, E. F. Articles by Palmer, H. P. Search for Related Content PubMed PubMed Citation Articles by Meehan, E. F. Articles by Palmer, H. P. Related Collections Health Philanthropy Mental Health/Substance Abuse State/Local Issues

GrantWatch

SPECIAL REPORT

Reinventing A Multicounty Behavioral Health Care System: The Local Philanthropy As Change Agent

They can (1) exert strong influence on the community through a strategic philanthropic agenda; (2) be an honest broker, since they are generally not perceived as benefiting from modifications in service delivery; (3) transcend political considerations and terms of office of elected officials; (4) respond more rapidly and adroitly than government, by deploying relatively small amounts of money in strategic, timely, and flexible ways; (5) approach difficult issues with credibility and serve as a convener, particularly for issues that are "orphaned" for political or economic reasons; and (6) leverage larger sources of funds to enable sustained change within systems of care.

Each of these attributes is seen in the following chronological case example of the work of a local philanthropy, the Dorothy Rider Pool Health Care Trust, in Allentown, Pennsylvania.

The mission of the Dorothy Rider Pool Health Care Trust, with approximately $100 million in assets, is to "serve as a resource that enables Lehigh Valley Hospital (LVH) to be a superior regional hospital and improve the health of the citizens of the region it serves." That region consists primarily of two counties in eastern Pennsylvania, Lehigh and Northampton, which together have a population of approximately 700,000.

Promoting Systems Change In Behavioral Health

 
In 1990 the system for delivering behavioral health services for the Lehigh Valley faced numerous challenges. As in many communities, mental health services delivery had been inadequate for decades. The system had relied heavily on Allentown State Hospital (ASH), which delivered inpatient long-term care for persons with psychiatric disabilities. Three community hospitals delivered acute inpatient care. Nonhospital community support services were available, but problems existed regarding access and effectiveness.

Consumers relied too heavily upon the community hospital emergency departments and inpatient mental health units, as well as ASH. Inpatient services were costly, and their overuse resulted in the inadequate development of flexible, coordinated, and effective community services. Low consumer satisfaction, high morbidity and mortality from suicide, poor quality of life, and high cost of delivering care resulted.¹ In 1990, in response to these challenges, the Pool Trust improved the level of clinical leadership in the region by helping to recruit and retain a new chair of psychiatry for LVH.

In 1993 the chair of psychiatry asked the trust to convene a series of meetings on the potential for a regional approach to mental health services delivery. Participants included human services directors from both counties, representatives of the United Way and the local community foundation, regional and state mental health officials, and key local service providers. Under the trust’s auspices, these persons developed a shared understanding of the challenges to high-quality service delivery. They began an ambitious process of restructuring the behavioral health care system for adults with psychiatric disabilities.

During 1995–1996 the Pool Trust funded $270,000 in three separate grants to (1) redirect services from episodic crisis care to community-based care; and (2) promote long-term support and community integration of clients. In this process, the trust sought shared qualitative and quantitative data to aid in decision making and knowledge of best practices and models from other communities.

Through a request for proposals (RFP) process, a consulting group with substantial expertise in behavioral health systems, the Centre for Community Change International (CCCI) of Burlington, Vermont, was selected to manage the change process. The RFP and selection of the consultant, which were overseen by the Trust, also enabled the group to adopt an inclusive approach to the challenge, by accepting all key stakeholders in a way that, while time-consuming, would increase the chances that decisions would be accepted by all constituents. The CCCI skillfully acted as a facilitator among the stakeholder groups by managing conflict and building consensus, and it provided the research on best practices.

Project Management

Top Promoting Systems Change In... Project Management Support For Ongoing Change Key Achievements Implications For The Future NOTES

 
Two work groups enabled broad participation and timely decision making: the Liaison Committee and the Advisory Council.

Liaison Committee. The Pool Trust recommended that a small work group meet monthly, at the trust’s offices, to solve emerging problems and keep the project focused. This group included key state and county officials. Despite differing institutional viewpoints, the participants remained cohesive over the course of the project. In fact, the effort survived the change of the governor of Pennsylvania and that leader’s party affiliation, change in governance of several community hospitals, a change in leadership in one county’s government, and a change of leadership at ASH.

Advisory Council. There was a need to provide a "place at the table" for all constituencies and to obtain a commitment from each of them to continue participating in spite of any recommendations that challenged their self-interest. The Advisory Council, facilitated by the CCCI, involved more than fifty consumers, family members, mental health providers, and others concerned about community mental health services. All agreed to work on the basis of consensus, even if that took a great deal of time.

This group developed bold, comprehensive recommendations for change, which were summarized in the report, informally called the Action Plan.² It contained an innovative design for the rightsizing of ASH and for appropriate community services. It also reflected a desire to conduct systems change within Pennsylvania Department of Public Welfare (DPW) policy on two matters: downsizing state hospitals and increasing community based mental health services.

County managers, providers, and advocates used this plan as a way to articulate and implement a shared vision of a consumer-oriented, family-supporting, outcomes driven, and cost-effective mental health system. In 1997 the Pool Trust funded an additional $200,000 for Action Plan implementation, to build capacity within the county systems for delivering mental health services.

Support For Ongoing Change

Top Promoting Systems Change In... Project Management Support For Ongoing Change Key Achievements Implications For The Future NOTES

 
In 1998 the Lehigh Valley Partnership (LVP), an organization representing the private sector leadership in the region, recommended "coordinated quality mental health services in the Lehigh Valley."³ The process developed by the CCCI in several locales and adapted by the Pool Trust and colleagues in the Lehigh Valley serves as a prototype to improve behavioral health services and other quality-of-life issues through a collaborative problem solving process.

This effort demonstrated that government, health care providers, and an array of diverse constituents could work together for a common purpose. This success has stimulated an ongoing effort to explore the development of a bicounty public health department. This activity is being led by the LVP and funded by the Pool Trust.

Key Achievements

Top Promoting Systems Change In... Project Management Support For Ongoing Change Key Achievements Implications For The Future NOTES

 
While no formal evaluation was conducted, the change in mental health services delivery can be measured by the tangible outcomes. By 1999 the Pool Trust–supported process achieved the following. More than $5.2 million of DPW funds were leveraged to build and expand community support services featured in the Action Plan. More than 100 long-stay ASH residents were successfully integrated into the community. Community services for clients who were at high risk for inpatient care were expanded. Clients’ use of the state hospital was greatly reduced. Vitally needed crisis services and alternatives to hospitalization were developed and implemented by the counties. Consumers were offered more choice of services. An independent Consumer Satisfaction Team consisting of consumers and family members was established to monitor and evaluate behavioral health services. Consumers were very satisfied with their care, an independent consumer satisfaction survey found.⁴

Implications For The Future

Top Promoting Systems Change In... Project Management Support For Ongoing Change Key Achievements Implications For The Future NOTES

 
A decade of work by the Pool Trust and colleagues has resulted in important clinical improvements and more resources for behavioral health services. These accomplishments are the result of the cooperative efforts of the LVH chair of psychiatry, the CCCI, key players in the Pennsylvania DPW and in county government, service providers, and consumer and family advocates. While this collaborative work built upon the lessons learned from prior cooperative efforts in this region, it is now part of the collective community wisdom that encourages cooperative problem solving for subsequent regional efforts to improve health and quality of life. The process—convening, facilitating, and sustaining an effort—will be encouraged again by the trust as the region continues to improve behavioral health services.

Key stakeholders in the region will need to ensure that the gains made over the past ten years can be sustained. Vigilance will be required to ensure that a continuing commitment to mental health system improvement will enable more Lehigh Valley community members with mental illness to live full and productive lives. This case example suggests that local foundations can play a unique and important role in local mental health policy, with implications for broader quality-of-life improvements.

Editor's Notes

 
Edward Meehan is executive director of the Dorothy Rider Pool Health Care Trust in Allentown, Pennsylvania. Michael Kaufmann is chair of psychiatry at Lehigh Valley Hospital in Allentown. Paul Carling is founding consultant, and Chip Palmer, president and chief executive officer, of the Centre for Community Change International in Burlington, Vermont.

The authors acknowledge the support of Elliot J. Sussman and express appreciation to the dedicated families, consumers, mental health workers, and public officials of Pennsylvania and the Lehigh Valley.

NOTES

Top Promoting Systems Change In... Project Management Support For Ongoing Change Key Achievements Implications For The Future NOTES

 

1. P.J. Carling et al., Implementation of the Action Plan for a Cost-Effective Behavioral Health Care System for Lehigh Valley Adults with Serious Mental Illness (Allentown, Pa.: Dorothy Rider Pool Health Care Trust, 14 February 1997).
2. Ibid.
3. J.A. Jordan Jr. et al., Lehigh Valley Spirit of Investment (Bethlehem, Pa.: Lehigh Valley Partnership, November 1998).
4. P.J. Carling et al., Creating a Consumer-Centered Family Supporting, and Outcome-Driven Behavioral Health Care System in the Lehigh Valley (Allentown, Pa.: Pool Trust, 15 April 1999).

                      What's this?