Background in Mental Health
I began my career as a case manager charged with state hospital “inreach” helping to find housing, coordinate services, and develop discharge plans for patients challenged with severe and persistent mental illness.
A case manager works to coordinate the safe release of seriously mentally ill adults and children in accordance State and Federal policy to treat individuals with mental illness and intellectual disabilities in their own communities first, in the least restrictive environment possible. https://gov.texas.gov/organization/disabilities/intellectual_disabilities_protections
I finished my Masters Degree in Public Administration degree while working in this direct care role for 5 years. I spent a few more years after as a program administrator. During those years, I gained experience in federal and state compliance, revenue cycle optimization and Medicaid cost reporting. I later moved to Midland as Chief Operations Officer and, after Midland I served in El Paso, Salt Lake City, and then started Project Itya, which I renamed Mind Stream AI https://www.garylarcenaire.com/gary-larcenaire-to-launch-practice-management-firm/
Each new opportunity to help lead, has required me to research, develop, refine and deploy new leadership constructs. This release outlines my perspective through theories I borrowed and modified, and the results yielded for the communities and clients I had the privilege of serving. Rubiks Cubes and Community Health outlines how I adapted organizational theories to improve management of the notoriously complex behavioral health sector https://www.healthleadersmedia.com/clinical-care/tackling-top-3-challenges-behavioral-health.
Where I worked, and the theories I adapted:
PermiaCare, Midland, Texas CSA pop, 250K https://www.permiacare.org/
At PermiaCare, I found myself facing seemingly infinite and competing challenges. In an attempt to organize the system, I borrowed principles from multiple thought leaders and organized our pressing demands and competing priorities. These needs fell into four broad, co-equal categories, and I organized them into quadrants.
Leadership meetings back then seemed too focused on money and billing, to the neglect of other important priorities like access and quality. To help broaden our focus,I drew out a circle on a dry-erase board, and divided it into four equal pie shaped triangles. Borrowing concepts from Kaplan and Norton, I developed a balanced scorecard structure, and labeled each piece as a broad category. They were: financial, compliance, care outcomes, and stakeholder satisfaction.
I then listed every challenge that was on my mind in the quadrant piece where it belonged. Some problems affected multiple quadrants at the same time. For example, hospitalizations were both expensive and a clinical failure. This process helped me organize my tasks, and to figure out what threats/challenges to the system were the most immediate.
I shared my idea with the team and began the process of adopting it into our daily practice. Over time, the quadrant idea evolved into more of a decision making model. We had developed a shared language around challenges/workflow conflict, and marveled at how often solving a problem in one quadrant had the potential to negatively impact one or all of the others.
Use of the quadrants process markedly improved team communication and diffused tension. Even the least confident person on the team learned to effectively advocate for, and defend, their own quadrant. They also learned to appreciate the demands and stresses of other team members who were advocating and defending other quadrants.
Over time, the deliberative process became easier and felt less like a personal attack. Opinions were better organized, more clearly expressed, and more supportive of the company goals and objectives. Individual personality quirks began to fade into stronger team cooperation. Our complex system, viewed through these types of lenses, behaved like a large Rubik Cube where the movement of one part of the cube directly affects other parts.
For example, if we balanced the budget and had fewer staff to deliver services it angered staff and stakeholders. If we increased safety awareness it caused a flood of property management problems to fix which overspent the budget. Same puzzle principles as work, just a lot more emotion, and urgency involved in running a complex health and social services system.
We introduced the concept of accountable task summaries, with clear deadlines, assigned task scribes, self-imposed deadlines, and we were off to the races. Permian went from “low- average” to a “top five” system. We were beyond proud to rank among the best Texas had to offer at the time. I hear the Midland system, recently branded as “PermiaCare” remains among the top performers in the Texas network.
All Quadrants are Created Equal
Solvency isn’t more important than quality clinical care. Money shouldn’t be saved at the expense of properly funding a system to detect fraudulent billing, or ignoring the general state of dissatisfaction with the services offered by the system. Ignoring any one of the quadrants over extended periods will end in market obsolescence.
Although some threats may be fatal over shorter periods, all four quadrants must be monitored and defended with equal zeal and administrative authority. This can be difficult when everyone knows the current ceo’s passion and background, as this can cause a bias in the subtle priorities of the system if not kept in check.
Regardless of the incumbent CEO bias (mine has been care coordination and hospital prevention) when a decision needed to be made, we ‘ran it through the quadrants’. It’s not hard once the team embraces it and a little time passes. Start by finding out what impact a proposal or idea for improvement may have on the other quadrants. If it is potentially negative, is there a compromise to mitigate the impact? There must be, to move forward.
For more information on the “quadrants” video
Emergence Health Network, El Paso Texas https://emergencehealthnetwork.org/
While serving in Midland, I came across the writings of Peter Senge. The Fifth Discipline transformed my thinking. I wasn’t alone. In 1997, Harvard Business Review identified this book as one of the seminal management books of the last 75 years.
Peter senge, founder and director of the society for organisational learning and senior lecturer at mit, has found the means of creating a ‘learning organisation’. In the fifth discipline, he draws the blueprints for an organisation where people expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nutured, where collective aspiration is set free, and where people are contually learning together. The fifth discipline fuses these features together into a coherent body of theory and practice, making the whole of an organisation more effective than the sum of its parts. In the same way a musician is influenced to create something new from their musical influencers, I was inspired to somehow tie the quadrant approach to Peter Senge’s theories and create something novel.
El Paso had always had a complex reputation in my field and recent legislative reports https://sao.texas.gov/reports/main/95-033.pdf had outlined some serious challenges The experiences of my predecessors had been brutal in the media, and their tenure short.
Prior CEO’s had unfortunate experiences and were publically ousted before their first or second year. I started my term as CEO, and moved quickly to introduce my processes in quadrant-based theory, while adding Senge’s decision making and feedback loop elements.
At the time, the most pressing threat to survival was state hospital “overuse”. Data revealed the system was taxing the rest of the state with psychiatric admissions, running 15 passenger vans twice weekly. Imagine thirty actively-psychotic patients, by definition a “danger to self or others”, per WEEK being admitted from El Paso County into somewhere, whether there was room or not. This had to stop. The organization needed to learn and adapt fast! I assembled a leadership team, and trained exhaustively on the quadrants, minutes master scribe, self imposed deadlines and “The Fifth Discipline”.
In about three months, my team of enthusiastic and talented executive leaders their programs and saved that system from financial ruin, and vastly improved the patient experience, engagement, and outcome levels.
Three months isn’t very long considering what we had challenging us. The team found IT networks with no virus protection software on the servers, no functioning firewall, unsafe and condemned buildings, patient recidivism surging through the state hospital system across Texas and dated revenue cycle processes–everything manual, depleted cash flow and fully depleted reserves. We were in a true spiral.
Among other powerful forces looming, was a not-so-subtle threat from a justifiably angry IT executive for Texas Governor Perry, who said we had nearly infected the Governor’s own work computer with the “my doom” virus. The man described El Paso’s IP addresses as the source of “nefarious cyber activity”. When he realized I had been installed as CEO that same week, he laughed and said “good luck, you’re going to need it”. I am grateful I never heard back from him. He had the political strength to take our system of care off the state network, which would have ended us. We would have had zero billing ability.
While much of the system seemed against us, El Paso also had a media-savy and pasionate probate court judge serving his community as an advocate for the mentally ill and elderly. https://www.mrt.com/news/article/Judges-say-elder-care-problems-are-statewide-7826965.php. Judge Max Higgs, with his quick wit, knowledge of the law, and forceful temper, earned a reputation of being able to reduce an administrator to tears in his courtroom. We became allies to the cause and worked collaboratively for years. I am grateful that we remain close to this day.
The Texas ranking data would describe El Paso as a superior system of care, only a few years later in 2006. It remained so, from then until my departure in 2011 when I moved on to lead a system of care in Utah in crisis.
The Dyad Approach
Valley Behavioral Health, Salt Lake City Utah https://valleycares.com/
When I arrived in Salt Lake City I was struck by the physical beauty of the area. The system of care had been in the news lately and the coverage was alarming https://www.cityweekly.net/utah/mental-hell-at-valley-mental-health/Content?oid=2145686
The contract that Valley had build their entire financial, clinical, reporting, and compliance design around had been awarded to Optum and things were very uncertain for Valley Behavioral Health. https://archive.sltrib.com/article.php?id=52028038&itype=cmsid
I was welcomed publicly as a “controversial ceo” given my public advocacy work in El Paso to press for more funding and accountability. My public advocacy work was not appreciated by some, and we endured stories that sought to stop our momentum. Thankfully, the unfair coverage, led by one particularly hostile journalist did not derail my career.
The Valley Board saw through the bias, and I was chosen as the next ceo of Valley Behavioral Health in 2011.
The first few years at Valley were very challenging. We were facing insolvency within my first quarter, and were stuck in a pension system that made our costs structure unsustainably high. I found myself in the unenviable position of having to find a way to exit the Utah Retirement System, and after two legislative sessions, we finally did it. This was the best, and worst professional accomplishment of my career. The URS problem was a perfect example of the Rubik’s cube metaphor. While the senior leadership congratulated itself for the URS exit, we all lost the ability to stay in the state pension system. Many stakeholders thought what we did was a terrible mistake. In this instance, the financial quadrant had to prevail because no reimbursement rates would have covered that cost.
In 2016, Valley Behavioral Health, was not improving quickly enough to keep up with the market demands of an exploding economy, robust population growth, and subsequent infrastructure strain. We were faced with evolving reimbursement designs, regulatory expectations, and an ambitious strategic plan that anticipated a “fully diversified and integrated community healthcare company”, with expansion plans to Idaho and Arizona. Valley’s trends, in all quadrants, were favorable after a few months of valiant effort by me and my executive leadership team, but performance improvement trends were not steep enough to ensure Valley would reach and maintain a leading competitive edge over the long haul. It was such a brutal truth to realize that and we started making some big changes.
We rebranded 500,000 square feet of building space. We took the company from $85 million in annual revenue to $45 million, and then back up to $75 million with new business lines and sources of revenue. We built a sophisticated data infrastructure and begun to refine our approach to community education and marketing. We installed a state of the art call center, with modern software systems that enabled chat and website interface. We refreshed the human resources department and addressed massive turnover after the loss of the pension benefit. We added new service lines year after year. We diversified our funding streams and strengthened the macro-business model of Valley. Vertically integrated pharmacy services and lab while launching successful EMR conversion.
CRM and Employee Engagement Software
When we added CRM and Peakon to monitor feedback from employees and stakeholders, we found rich opportunities to improve. We agreed to double down on a more regimented adherence to the principles of the quadrant approach to try and improve employee and stakeholder relationships. To solve these problems, and to ensure clinical care was on par with the best in the industry, We decided to elevated new leaders, and add a dyad design https://www.acc.org/latest-in-cardiology/articles/2020/06/01/12/42/business-of-medicine-dyad-leadership-model-walking-the-talk
The “dyad’ in hospital administration refers to a leadership model typically consisting of an administrative leader and an MD, who are closely partnered and share decision making, while aligned to the same clear goals. Our dyad approach is modified to better fit community health and social services needs, but the principles of shared accountability and goals are the same. Our experimental and evolving dyad is split between “business-oriented” and “client centered” skillsets. Waking up everyday with both priorities being your obsession ensures you will likely do neither well.
At the executive level, we developed a dyad structured, quadrant based, feedback loop focused learning design. Licensed on-site leadership was retitled to “Attending Clinicians”. These “AC’s” serve as the unit experts in all areas of “clinical”.
We worked collaboratively to reduce caseloads and improve training and guidance/meeting attendance.
Valley Behavioral Health As of the Time of this release enjoyed:
- Psychiatric emergency hospital use trending down nearly 40% (2019-20) (Clinical Quadrant)
- External/Internal audits reveal an effective and healthier compliance system validated externally by uncomfortably probative annual reviews. (Regulatory Quadrant)
- Financials now permit expansion efforts and enhanced employee compensation levels since 2016. (Financial Quadrant)
- Stakeholder Satisfaction (Non Employee) 3.7 on a scale of 5.0
- Employee Engagement Valley performs in the top 25% in the health care space. (Stakeholder Quadrant)
- Customer satisfaction 4.7 on average across all programs on a 5.0 scale. (Stakeholder Quadrant)
The dyad approach combined with a solid platform to facilitate organizational learning, launched the Valley system of care into elite levels of performance across the quadrants and ensured Valley’s status as a leader. I was thrilled to receive a glowing letter from my board chair when my work concluded in Utah https://www.garylarcenaire.com/valley-endorsement-for-gary-larcenaire/
By 2019/2020, after Covid, my health was suffering and I decided things needed to change. https://www.garylarcenaire.com/my-year-in-review/ I wrapped up my contract with Valley and decided to tour the country and explore the mountain bike and rails to trails we are blessed with in this country. https://www.railstotrails.org/
After 10 months of touring, I was contacted about a small not for profit in Montana that had endured a full leadership transition at the executive level. I served that program to the best of my ability and then found myself facing some unfortunate media controversy https://www.garylarcenaire.com/larcenaire-endorsement/, thankfully, like the brave Board in Salt Lake, they supported my work.
Behavioral health is a challenging and yet rewarding field. It’s importance and acceptance after Covid has been recognized to levels I never imagined were possible given the stigma surrounding it for most of me career. Combining the complexity and urgency of higher profile “turnarounds” with the inherent complexity of health and human systems added a level of puzzle difficulty that I could have never understood when I embarked on this journey. My focus will be coaching and system optimization moving forward. I will leave complex turn arounds to the younger generations!
I am working on a start up of a series of elite level outpatient clinics now named after the concepts at the core of Itya Mind Stream AI. https://www.linkedin.com/company/project-ity%C3%A2/?viewAsMember=true Thank you for following my page and I hope to interact with you in the comments section and on Linkedin.