I read, with interest, a recent piece on the future of U.S. hospitals,  Service-line strategies for US hospitals, by the consultants of McKinsey & Company. The premise is quite simple – the full service hospital is going to have an increasingly difficult time competing. Their solution? "A commitment to clinical service lines as an organizing paradigm, much as many corporations organize themselves by business unit—is becoming a necessity. . . Specializing in a few service lines allows hospitals to build a critical mass of patients in select areas and to enjoy economies of skill and scale... "

This market focus on specialization – and the need to adopt service line management tools is not limited to hospitals. I see it as a key survival strategy for organizations in the behavioral health and social service niche playing field.

At our 2010 OPEN MINDS Strategic Planning Institute last month, I presented our recent analysis of our post-recession, post-health care reform model for specialists. In a nutshell, there are four likely delivery system market positions – two in facilities and two that are tech-enabled:

• Destination Specialty Services
• One-Stop Health Service Shopping
• Mobile, Home-Based, & Community Care Services
• E-Health & Remote Services

But, that is only part of the strategic positioning story. Within those delivery system market segments, the detail can only be answered by effective service line analysis and management. For your strategic planning – and then for your on-going market strategy implementation and operations management structure – service line management models are key to effective analysis and nimble management during this turbulent market environment. If your current planning isn’t grounded in an organizational view based on service lines, consider next year’s plan as a good place to start today.

Just in case you've missed it, there is a bill wending its way through Congress to extend the HIT/EHR incentives that are available to all other health care provider organizations through the Stimulus (ARRA) funds to behavioral health. On April 15, 2010, Congressman Patrick J. Kennedy (D-RI) and Congressman Tim Murphy (R-PA) introduced the Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040). The bill adds mental health and substance abuse professionals, psychiatric hospitals, substance abuse treatment facilities, community mental health centers, psychologists and clinical social workers to those eligible for electronic health record incentive payments established under the American Recovery and Reinvestment Act of 2009 (ARRA). Psychiatrists and psychiatric nurse practitioners are already eligible for this program under existing law.

You can learn about the bill at http://patrickkennedy.house.gov/PRArticle.aspx?NewsID=1770. We'll keep you posted on the status of the bill in our coverage of breaking developments in the field.

An article in the November 30, 2009 issue of The New York Times sparked my thinking, once again, about the high attrition rate of behavioral health and social service organizations. The article, "Less Diversity in Supervisors of Foster Care” cites the statistic that under the watch of John B. Mattingly, appointed in 2004 to head New York City’s Administration for Children’s Services, the number of foster care agencies has dropped from 43 to 33.

A little later in the article, Fatima Goldman, executive director and chief executive of the Federation of Protestant Welfare Agencies, observed that the cause was just a lack of time for agencies to develop the management infrastructure needed for the current environment. “There just hasn’t been time for some agencies to build the core infrastructure to survive such a dramatic shift that’s occurred over the last few years, especially the overall economic downturn…That is the nail in the coffin for so many organizations.”

Talking about ‘time’ alone as the demise of many of the non-profit organizations isn’t dealing with the ‘whole picture’. There are a few other factors:

• Inability (or unwillingness) of public purchasers to measure and compare the performance of their contract organizations—have transparency in performance and make future referral, rate, and contracting decisions on that performance data
• View of the leadership of the organizations in the field that management capabilities are not integral to continuing their service mission; this has been permitted to exist by public purchasers for years and reinforced by the good intentions of management teams.

Time is now an issue for many organizations in the field. They have, indeed, waited too long to put in the management systems—financial, IT, planning, development, etc.—that they need to make it through the next decade.

Wired Magazine never fails to make me think. The October 2009 issue featured “The Smart List: 12 Shocking Ideas That Could Change the World.” There were six ideas that have specific relevance to our field:

1. Recruit Autistics. "A preternatural capacity for concentration and near-total recall" makes autistic folks ideal software engineers according to Thorkil Sonne, who founded Specialisterne in Denmark, an IT consultancy that hire mostly people with autism-spectrum disorders.
2. Embrace Human Cloning. Human clones walk among us—identical twins—so why not take in vitro fertilization to its logical conclusion?
3. Make Health Risk Management Meaningful. According to Ralph Keeney, 55% of deaths for people aged15 to 64 are now due to their own decisions—compared to 5% a century ago. Provide people with better calculations of risk (for not using seatbelts, not exercising, bad diets, etc.) and then adjust health premiums accordingly.
4. Release All Nonviolent Offenders in Prison. Incarcerating nonviolent criminals costs us $22,000 per year—and has no social gain. Make nonviolent offenders go to counseling, get an education, do public serivce, and repay their victims.
5. Legalize Assisted Suicide. Ludwig Minelli, founder of Dignitas, a right-to-die organization, believes that prohibiting suicide doesn't keep desperate people from trying. Instead, provide dignified options—and counseling for people considering suicide.
6. Forget Medical Privacy. Guest commentator Jamie Heywood of PatientsLikeMe believes "privacy has been used as an excuse by those who have a vested interest in hoarding" health care information. He wants us to share our personal data on-line in social communities.

You may or may not agree with them—but, if implemented, they certainly will change our world.

The report in USA Today was brief, but its implications leapt off the page for me:

“In the eight states that report monthly tax figures, collections from July through September declined an average of 8.3 percent from a year earlier. Even in places where there's been an income tax increase, such as New York, collections still declined. This comes after there was a 15 percent nationwide drop in tax collections during the first six months of the year.”

With health care in general (and behavioral health and social services in particular) dependent on state financing, I think the ‘end of the recession’ is nowhere in sight – despite the pronouncements of economists. Look for reductions in Medicaid (reduced eligibility, reduced service coverage, reduced provider fees, and more risk-based contracts) and cuts in state-funded services (mental health, addictions, child welfare, juvenile justice, prison health, senior support services, etc.) as the reality of tax collections cause state governments to open up their budgets once again.

If you’re a manager of an organization providing health services or social services – or a county commissioner – the pending tax shortfalls will have the biggest impact on your work. Now would be the time to develop a contingency plan.

For more on planning and managing in these harsh economic times, check out:

• On the Money - The Key Financial Challenges Facing Nonprofits Today - and How Grantmakers Can Help
• The Wolf is at the Door: The Global Economic Crisis and the Public Sector
• Surviving & Thriving in a Recession: A Management Blueprint for Health & Human Services
• Changes in Health Care Financing & Organization: Impact of the Economy on Health Care

I read not long ago that the State of Georgia is sending released sex offenders to live in a camp in the woods near Marietta, Georgia—even those who own their own homes. There are a myriad of factors that have lead to this situation—zoning laws, parole requirements necessitating these individuals to stay a certain distance from children, and lack of suitable housing (the Associated Press reported that "there is only one homeless shelter in Georgia that fulfils the residency requirements for sex offenders, but it only has two beds, which are usually occupied."). I don't think it's acceptable for our leaders to throw up their hands about the inevitability of this situation, as if they were powerless to effect change.

I find this to be part of a troubling change in our view of the acceptability of treating ‘undesirable’ fellow citizens inhumanely. I think this change in thinking is a threat—a slippery slope in the floor of acceptable treatment—for the consumers we serve. One day it's okay to send people to jail because they have no mental health treatment (they need to exhibit some self control and not act in ways that will land them in jail); the next day it's acceptable to close critical health care services that will result in the death of uninsured persons (who should work hard enough to have insurance); and then we can sentence people (dastardly people who prey on children) to living in encampments without even the human supports of leper colonies of old.

In the behavioral health and social service niche, we serve and advocate for a group of individuals unattractive in popular culture. Runaway teens living on the streets, drug addicts, "the retarded", and more. I caution us all to not stand by when this growing acceptance of inhumanity occurs. For those of you who are not swayed by dewy-eyed humanitarian thinking, you can ponder the immortal words of Ronald Reagan who said, "Protecting the rights of even the least individual among us is basically the only excuse the government has for even existing…”