One change leads to another: Volunteer Behavioral Health Care System

Submitted by: 10/15/2012 by Maureen Fitzgerald


Volunteer Behavioral Health Care System (VBHCS) is a non-profit organization serving 31 counties of middle and east Tennessee. Its 58 service locations provide out patient services, medication management, case management for patients with mental illness, addiction, and co-occurring disorders to nearly 60,000 patients each year. Specialty programs include programs for re-entry, a behavioral health court, and an eTherapy program called MyRecovery.

Says Vickie Harden, Senior Vice President of Clinical Services, “Change is hard in a company this size—it gets really unwieldy really fast. You can’t do too much too soon. NIATx has been a great way for us to understand how to implement change in small increments.”

The VBHCS offender reentry program (ORP) in Murfreesboro, Re-Entry and Recovery Tennessee (R&RTN), was one of five grantees in the 2011–2012 NIATx ORP Learning Collaborative. Funded by SAMHSA, the collaborative taught the sites to use the NIATx model to improve access to and retention in treatment for the addicted offenders they serve.

R&RTN helps inmates who suffer from substance abuse or co-occurring mental illness disorders make the transition from jail back to their communities. It serves 11 county jails in the VBHCS service area—10 rural and one urban. R&RTN also works with probation and parole, mental health centers, and other community support agencies to help clients gain access to all the resources they need to prevent re-incarceration and achieve lasting recovery. It screens about 750 clients per year and serves 650.

R&RTN recognized that clients were not continuing in outpatient treatment at the local community mental health center after intake.

Baseline data previously measured at three different intervals showed that the rate for return appointments after intake was 62%. The change team set a goal to increase the continuation rate to

They applied the first NIATx principle, “understand and involve the customer” in creating their pilot test: a four-time questionnaire for clients to complete after intake. Responses to the questionnaire indicated that transportation and having to take time off of work were significant barriers to continuation.

But this customer-friendly change did not have the intended affect: continuation actually dropped to 57% after the change was implemented. Rather than try to address the identified barriers, the team abandoned the questionnaire.

Explains Harden, “Though abandoned the change, this project really forced us to look at the data in a way we had not before.” In fact, the data showed that during the change cycle, 100% of patients scheduled within 10 days after the first intake attended the first treatment session. This striking finding lead the team to focus on the critical importance of scheduling clients for treatment within 10 days of first contact. 

Figure 1

“Gathering data was the real bonus for the R&RTN change project. It showed us that helping clients manage their barriers is less important than reducing waiting time to treatment,” adds Harden.

Based on findings from the initial project, VBHCS has started another small change project that could have system-wide impact. Illness Management and Recovery Groups will begin within 10 days of the initial appointment at one location in the system. “This project should also improve retention by engaging clients within that crucial 10-day window,” says Harden. “If it works, it would be easy to replicate across the system.”

Harden credits the NIATx pilot project with helping shake up some long-held perceptions about poor continuation rates. “We’d had a “that’s just the is they way it is” attitude. But when we took a closer look, we began to see that we didn’t have to accept that.”  As an executive leader, Harden found that making change incrementally builds grass roots support among staff, leading to more efficient spread. “Starting from this perspective will have a great impact on how we conduct our change projects.” 

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