Summary
Historically, behavioral health services have been delivered separately from medical care and often in physically unappealing settings. Additionally, the behavioral health field suffers from a high rate of staff turnover. Creative Health Services has addressed these issues through the integration of primary care, pharmacy, social work and behavioral health services; new headquarters that provide a pleasant environment for clients and employees; and a commitment to employee wellness and development.
Challenges in the Behavioral Health Field
A great deal of improvement is needed in the diagnosis and treatment of behavioral health issues and in the coordination of behavioral and physical health. On the primary care side, many serious mental illnesses remain underdiagnosed and undertreated (Regier et al. 1993). On the behavioral health side, many individuals with serious mental illnesses (SMIs) have co-occurring medical conditions such as obesity, diabetes and tobacco use that would benefit from active management in a primary care setting. However, many of these individuals lack access to quality physical care and have relatively poor levels of adherence to prescribed treatments (Waxmonsky 2008). Currently, individuals with SMIs die an average of 25 years earlier than the general population (National Council for Community Behavioral Healthcare 2007), a number that could be substantially improved in a system with coordinated, high-quality behavioral and physical health care.
Additionally, behavioral health services are often delivered in physically unappealing environments, which can be detrimental to achieving clients’ treatment goals. A Center for Health Care Design study found that care environments that do not feel safe can increase patient stress levels; such poor design elements can include tight spaces with low ceiling heights, overly loud air systems and limited access to natural daylight (Sadler 2004). In contrast, behavioral health treatment settings with features such as earth tones, natural light, attractive furnishings and access to the outdoors have been shown to promote healing and recovery (Department of Veterans Affairs 2010). Physically unappealing environments also present stressful working conditions for behavioral health workers. These conditions, coupled with low pay rates, contribute to high rates of employee turnover in the behavioral health field (Aarons and Sawitzky 2006).
The Creative Health Services Approach
Creative Health Services (CHS) is a nonprofit, outpatient behavioral health agency based in Pottstown, Pennsylvania. Founded in 1957, CHS has grown into a multisite agency serving over 5,000 children and adults annually in Montgomery, Chester and Berks counties. Andrew Trentacoste, CHS’s Executive Director, is a clinical psychologist with both a PsyD and MBA. Prior to joining CHS in 2006, Dr. Trentacoste managed a variety of behavioral health programs. He has brought lessons learned from his past clinical and business experiences to Creative Health Services. During his tenure, CHS has undertaken new initiatives to integrate physical and behavioral health care, to implement evidence-based healthcare design to promote a healing environment, and to provide a supportive environment for its staff.
Integrated Physical and Behavioral Health Care
In September 2008, CHS opened its current 43,000-square-foot headquarters in Pottstown. To finance the new building, CHS took out $5 million in loans. After making this initial financial commitment, CHS was able to attract outside funding, including multiyear grants from the Pottstown Area Health & Wellness Foundation and the United Way of Southeastern Pennsylvania. The counties that CHS serves also invested via financial and other forms of support. In addition, CHS has generated rent revenue by acquiring tenants at its new location, including the regional office of the United Way of Southeastern Pennsylvania, a Montgomery County office of the National Alliance on Mental Illness, and Community Health and Dental Care, a new nonprofit health center that opened concurrently with CHS's move to the new facility.
CHS coordinated with local service providers and county agencies to provide integrated care with multiple services located in the same building, including medical care, a pharmacy, dental services and social work. Creative Health also has a staff of navigators (professionals with backgrounds in nursing, social work or psychology) who help clients with both their primary and behavioral health care. They may assist with scheduling and accompanying clients to doctors’ appointments. They also counsel CHS clients on many aspects of their health, including medication adherence, smoking cessation and weight loss.
Welcoming Environment for Clients
In addition to his training in psychology and business, Dr. Trentacoste came to CHS with a background in organizational design and construction, which he was able to apply to the design of CHS’s new headquarters. As noted earlier, mental health facilities are often run-down and unwelcoming. Their relatively poor design and condition can affect both staff and client morale, as well as treatment outcomes.
According to Dr. Trentacoste, one of the goals of the new design was to cultivate a feeling of openness, which begins when clients call to make an appointment. He feels that medical and mental health centers often underestimate the importance of customer service. To create a feeling of accessibility and openness, Creative Health has a live operator answer the phone to connect clients to the services they need without their having to navigate an automated phone system. This openness extends to the waiting room area, where no plastic barrier or wall separates the front desk staff and clients. Soothing design aspects extend to the earth tones of the building’s interior, and artwork (some by clients) that is displayed throughout the building. Quiet “spa music” is also piped throughout the building to create a relaxing atmosphere. The music serves the secondary purpose of ensuring privacy by covering sounds from therapy rooms. The CHS website contains photos and a video that further illustrate the building’s design features.
Staff Development
When Dr. Trentacoste assumed leadership of CHS, he set a goal of “flipping the organizational chart.” He sees his role as “supporting the people of Creative Health.” As a result, the Executive Director and the Board of Directors are on the bottom of CHS’s organizational chart with program staff above them. Speaking directly to the organization's mission, "the communities we serve" are at the top of the organizational chart.
Dr. Trentacoste recognizes that the behavioral health field generally has low pay and high turnover, and has told his staff he wants CHS to be “an average salary payer with above-average benefits.” Among those benefits are the new headquarters, which offers quiet office spaces with plenty of natural light. The staff also has a breakroom with a full kitchen and a treadmill for lunchtime exercise. Most staff members use these amenities frequently. CHS also offers a number of employee benefits; the organization has absorbed the bulk of recent increases in health insurance costs, funds retirement accounts for employees, and also funds gym memberships and wellness programs.
Impact
Since the new CHS building opened in late 2008, client volume has increased by 40 percent. Furthermore, the no-show rate for initial appointments has decreased roughly 10 percent, with similar increases in show rates following initial appointments. CHS staff has received a great deal of informal positive feedback from clients, and overall client satisfaction rates improved from the fourth quarter of 2008 to the first quarter of 2009. Also, in a 2009 survey administered by CHS, the majority of clients strongly agreed that the presence of primary care, dentistry and pharmacy was helpful, and that the site was easily accessible by transportation (Creative Health Services 2009).
In addition to satisfaction surveys, CHS uses evidence-based quality assurance/improvement tools to assess the impact of each of its programs. One such tool is the Behavior and Symptom Identification Scale (BASIS-24), which measures changes in an adult consumer’s self-reported symptoms. On this measure, CHS consistently scores among the top behavioral health providers in the country for client perceptions of care and for significant improvements in clinical measures of client care over time. For clients participating in their new integrated care program, CHS will track additional outcome measures to assess the impact of their model, including body mass index, glucose levels, blood pressure, lipid profiles and smoking status.
Changes at CHS over the past several years have also had a marked impact on the bottom line, with CHS experiencing 10 percent year over year increases in revenues and consistently positive cash flows. This allows the organization to further invest in its staff, mission and facilities. The most recent project made possible by an improved bottom line has been a complete overhaul of its children's partial hospital program. A school-based partial hospitalization program has been developed in the Pottstown school district, resulting in a program space that is open, inviting and kid-friendly. Furthermore, CHS’s strong service delivery outcomes and fiscal success have enhanced the organization's ability to raise funds and apply for competitive grants.
CHS leaders continuously monitor staff retention and other measures of the organization’s health and sustainability. Since the opening of the new headquarters, staff retention has increased. Additionally, CHS utilizes TCCGroup’s Core Capacity Assessment Tool (CCAT). The CCAT measures Organizational Leadership, Adaptive Capacity, Management Capacity and Organizational Capacity, which factor into a formula that calculates organizational sustainability. According to the TCCGroup, only 14 percent of nonprofits meet the CCAT’s sustainability test; CHS was ranked within that elite 14 percent (Creative Health Services 2009). Finally, Dr. Trentacoste has also received recognition for his leadership from the Philadelphia Business Journal, which named him as one of its top 40 area leaders under 40 years old.
Next Steps
CHS plans to continue its efforts in integrated primary care. The organization is participating in a statewide integrated care demonstration project. They have also received inquiries from other organizations interested in replicating their integrated care model and design features. In addition, CHS is serving as a regional host site for the University of Massachusetts’ Certificate Program in Primary Care Behavioral Health Collaboration. In addition to its integrated care efforts, CHS will continue delivering high-quality behavioral health services in a welcoming environment that is supportive for both clients and staff.
About the innovator
Dr. Andrew Trentacoste has been the Executive Director of Creative Health Services, Inc., since 2007. During that time, he has overseen the redesign and redevelopment of the agency, its mission, and clinical and business operations, culminating in the development of a new main treatment facility. A Pennsylvania licensed psychologist, Dr. Trentacoste received both his doctorate in Clinical Psychology and his MBA in Health Administration from Widener University in 1997. Prior to joining CHS, Dr. Trentacoste administered and developed a variety of innovative treatment programs in Philadelphia. Dr. Trentacoste is passionate about building and design, skills he regularly employs in his current role.
References
Aarons, G. A. and A. C. Sawitzky. (2006). Organizational Climate Partially Mediates the Effect of Culture on Work Attitudes and Staff Turnover in Mental Health Services. Administration and Policy in Mental Health and Mental Health Services Research 33(3): 289-301.
Creative Health Services. (2009). 2010-2013 Strategic Plan. Available at http://www.creativehs.org/Files/Creative%20Health%202010-2013%20strategic%20plan-%20smaller%20file.pdf.
Department of Veterans Affairs (2010). Office of Office of Construction and Facilities Management. Mental Health Facilities Design Guide. Available at http://www.cfm.va.gov/til/dGuide/dgMH.pdf
National Council for Community Behavioral Healthcare. (2007, June). An Avoidable Tragedy—The Relationship of. Premature Death and Serious Mental Illness. National Council Fact Sheet. Available at http://www.thenationalcouncil.org/galleries/policy-file/AnAvoidableTragedy.pdf.
Regier, D. A., W. E. Narrow, D. S. Rae, et al. (1993). The de Facto US Mental and Addictive Disorders Service System. Epidemiologic Catchment Area Prospective 1-year Prevalence Rates of Disorders and Services. Archives of General Psychiatry 50(2): 85-94.
Sadler, B. L. (2004). No Opportunity Wasted. Interiors and Sources 12(1): 64-65.
Waxmonsky, J. A. (2008). Main Outcomes for a Medicaid HMO Population with Multiple Medical and Psychiatric Comorbidities. Collaborative Family Healthcare Association Annual Conference.