CCBHC and Culture: There and Back Again

When community mental health had its start, the newly formed organizations had a mandate: they were to provide five “essential services” – inpatient, outpatient, day treatment, emergency services, and consultation and education. The organizations were largely federally funded and the populations to be served quickly grew from adults to include children and not long after, individuals with substance use disorders. The funding was blind as to recipient income and the hope was that the creation of these organizations, and the advent of Medicaid and insurance, would eventually lead to comprehensive coverage across the country. As we know, that never happened, and organizations originally established around lofty and aspirational missions fell victim to the realities of doing what you got paid for and serving only a restricted subset of the population. The concept of a CMHC faded from the federal system.

The narrowed scope did not mean the end of mission-driven work. Indeed, most CMHCs worked hard to remain aspirational while dealing with the harsh reality of the healthcare system’s lack of attention to behavioral health, often finding ways to provide what no one paid for. Government healthcare funding and development increasingly went to federally qualified health centers; they also became the focus for the integration of physical and behavioral health. CMHCs continued to address critical needs, but with a narrowed focus on the most seriously ill and economically depressed patients in the system. For many organizations, Infrastructure investments were difficult as funding was not available for facilities and technology (CMHCs were not included in the appropriations that reimbursed hospitals and physicians for EMRs, for example). The sense of scarcity could hardly be avoided as it meant lower salaries, the need to triage patients, and constrained investment in growth. It often became part of the organization’s culture.

 Then, after years of hard work, the concept of the CMHC re-emerged in the creation of CCBHCs with their emphasis on a broad range of services, while adding accountability measures.

In prior pieces about the CCBHC model and standards, we examined those modernized elements that CCBHCs added: defined staffing and data requirements. While those articles touched on culture as a component of recruitment and retention, they didn’t look at organizational culture as it morphed during the CMHC story – the transitions from organizations founded on lofty aspiration and hope to lofty aspirations constrained and frustrated by scarcity.  

For some organizations, having faced decades of underfunding, a scarcity mindset took hold, even as they held on to their mission of service. That was often seen in foregoing investment in staff and infrastructure in order to preserve services long past their financial viability.  This mindset meant that promotions and raises were held back, creating a vicious cycle in which staff left to enter “the private sector”, which was seen as having a bigger slice of the financial pie. Resources in a scarcity-ruled environment also limited investments that could promote growth are passed by. When resources are scarce, micromanagement abounds as financial management leads to implementing tight controls over most processes, and generally, short-term thinking is the norm. When scarcity pervades the culture, it diminishes the ability to see the lofty mission as achievable and can make an organization internally focused and isolated – the mission becomes a distant vision.

The CCBHC funding strategies shifted the ground beneath the feet of many organizations that had operated under much more financially constrained systems. Suddenly, they became much better resourced. Staff could be better supported. Prospective payments in the initial grants made cashflow less of an issue and the reimbursement was cost-based.

Abundance as a mindset was now a possibility, but one that could require a culture shift for organizations whose culture had become one of scarcity. Organizations should ask, have we moved from “We cannot afford that,” to “We should invest in that?” Abundance supports management processes that encourage innovation and some risk-taking rather than tight controls. Abundance values effectiveness over efficiency that is defined solely in terms of cost. It allows for consideration of approaches and technologies that can improve outcomes and be more efficient even if the latter takes time to manifest. It allows for looking at staff and implementing strategies to support their full potential through training and development. An abundance-focused organization seeks new partnerships and relationships that leverage communities’ strengths, recognizing wellbeing is not a zero-sum game. These are all relevant to successfully creating and managing a CCBHC compliant agency.

The core of most CMHCs’ mission statements remains essentially the same as it was early on, despite decades of underfunding and wording difference: providing behavioral healthcare in ways that make people’s lives better and enhance community wellbeing. Mission and culture are affected by the organization’s perception of the environment in which it operates. Scarcity constrains, abundance expands. If an organization has been focused on constraint in its staffing, development, management, and financial practices, it may not take full advantage of its new-found wealth through expanding its internal and external reach. An abundance mindset focuses on expanding reach, making wise investments in its infrastructure and people.

The mission of an organization and the goals and requirements of the CCBHC model are well aligned with each other, but the culture of the organization and its focus on scarcity (constraint) versus abundance (expansion) can make that alignment a reality or make its achievement more difficult. So, organizations should ask themselves how their cultural practices around dealing with scarcity have also precluded consideration of a more abundant environmental and practical approach.

This is the third in a three-part blog series examining the CCBHC model, requirements, and cultural shifts that are leading to progress in service delivery and outcomes. View part 1, CCBHC: Promise and Challenges, and part 2, CCBHC: Do You Have the Information?, to learn more.