Gary Larcenaire

Rubik's Cubes and Community Health

September 8, 2020 — Gary Larcenaire

Background in Mental Health

I began my career as a case manager charged with state-hospital "inreach" — finding housing, coordinating services, and building discharge plans for patients living with severe and persistent mental illness.

A case manager coordinates the safe release of seriously mentally ill adults and children in accordance with state and federal policy: to treat people with mental illness and intellectual disabilities in their own communities first, in the least restrictive environment possible.

I finished my Master's in Public Administration while working in that direct-care role for five years, then spent several more as a program administrator. In those years I built experience in federal and state compliance, revenue-cycle optimization, and Medicaid cost reporting. I moved to Midland as Chief Operations Officer, and from there I led systems of care in El Paso and Salt Lake City.

Each chance to lead has required me to research, develop, refine, and deploy new leadership constructs. What follows is the perspective I built — the theories I borrowed and modified, and the results they produced for the communities and clients I had the privilege of serving. It outlines how I adapted organizational theory to manage the notoriously complex behavioral-health sector.

Where I worked, and the theories I adapted

PermiaCare — Midland, Texas (catchment population ~250K)

At PermiaCare I faced what felt like infinite, competing challenges. To organize the system, I borrowed from several thought leaders and grouped our pressing demands into four broad, co-equal categories — quadrants.

Leadership meetings then were too focused on money and billing, to the neglect of priorities like access and quality. To widen the focus, I drew a circle on a dry-erase board and split it into four equal pie-shaped pieces. Borrowing from Kaplan and Norton's balanced scorecard, I labeled each one: financial, compliance, care outcomes, and stakeholder satisfaction.

Then I listed every challenge on my mind in the quadrant where it belonged. Some sat in more than one at once — a hospitalization was both expensive and a clinical failure. The exercise organized the work and made clear which threats were most immediate.

I shared the idea with the team and we built it into daily practice. Over time the quadrants became a decision-making model. We developed a shared language for workflow conflict, and we kept noticing how often solving a problem in one quadrant damaged one or all of the others.

The process markedly improved communication and diffused tension. Even the least confident person on the team learned to advocate for and defend their quadrant — and to respect the demands on colleagues defending the others. Deliberation got easier and felt less like a personal attack. Opinions were better organized, more clearly expressed, more aligned to our goals. Personality quirks faded into stronger cooperation.

Viewed through these lenses, our system behaved like a large Rubik's cube: move one face and the others shift. Balance the budget with fewer staff and you anger staff and stakeholders. Increase safety awareness and you trigger a flood of property-management costs that overrun the budget. The same puzzle principles — just with far more emotion and urgency.

We introduced accountable task summaries with clear deadlines and assigned scribes, and we were off to the races. PermiaCare went from "low-average" to a "top-five" system. We were proud to rank among the best in Texas, and I'm told the Midland system remains a top performer today.

All Quadrants Are Created Equal

Solvency isn't more important than quality clinical care. Money shouldn't be saved by underfunding fraud detection, or by ignoring dissatisfaction with the services a system offers. Neglect any one quadrant over time and you end in market obsolescence.

Some threats are fatal over shorter periods, but all four quadrants must be monitored and defended with equal zeal and authority. That's hard when everyone knows the sitting CEO's passion and background — it biases the system's priorities if it isn't checked.

Whatever the CEO's bias — mine has always been care coordination and hospital prevention — when a decision had to be made, we "ran it through the quadrants." It isn't hard once the team embraces it. Start by finding what a proposal does to the other quadrants. If the impact is negative, is there a compromise that mitigates it? There has to be, to move forward.

Emergence Health Network — El Paso, Texas

At Midland I came across the writings of Peter Senge, and The Fifth Discipline transformed my thinking — I wasn't alone; Harvard Business Review named it one of the seminal management books of its era. Senge draws the blueprint for a "learning organization": where people continually expand their capacity to create the results they truly want, where new and expansive thinking is nurtured, and where the whole becomes more effective than the sum of its parts. The way a musician builds something new from their influences, I set out to fuse the quadrant approach with Senge's theories into something of my own.

El Paso had a complex reputation in my field, and recent legislative reports had outlined serious challenges. The job had a short shelf life — prior CEOs had been publicly ousted inside a year or two. I started as CEO and moved quickly to introduce the quadrant process, adding Senge's feedback-loop and learning elements.

The most pressing threat to survival was state-hospital "overuse." The data showed the system was taxing the rest of Texas with psychiatric admissions — running fifteen-passenger vans twice a week. Picture roughly thirty actively psychotic patients per week, by definition a danger to self or others, admitted out of El Paso County into wherever there was room, whether there was room or not. It had to stop. The organization needed to learn and adapt fast. I assembled a leadership team and trained exhaustively on the quadrants, master-scribe minutes, self-imposed deadlines, and The Fifth Discipline.

In about three months, that team of talented executive leaders stabilized their programs, pulled the system back from financial ruin, and measurably improved patient experience, engagement, and outcomes.

Three months is not long, given what we faced. The team had inherited IT servers with no virus protection, no working firewall, condemned and unsafe buildings, recidivism surging through the state-hospital system, fully manual revenue-cycle processes, and depleted cash and reserves. We were in a true spiral.

Among the forces against us was a justifiably angry IT executive in Governor Perry's office, who said El Paso had nearly infected the Governor's own computer with the MyDoom virus, and described our IP addresses as the source of "nefarious cyber activity." When he learned I'd been installed as CEO that same week, he laughed and said, "Good luck — you're going to need it." He had the power to take our system off the state network, which would have ended our billing and ended us. I'm grateful I never heard back from him.

El Paso also had a sharp, passionate probate judge who served as an advocate for the mentally ill and the elderly. Judge Max Higgs — quick wit, deep knowledge of the law, and a temper that had reduced more than one administrator to tears in his courtroom — was not an easy ally to win. What won him was the method, not me. Years later, describing publicly how the El Paso turnaround had actually worked, he put it plainly: I had identified the major stakeholders and worked with them collaboratively. That was an outsider — and a hard one to impress — naming the same alignment method I'd built at PermiaCare and carried into every system since, in his own words and on his own initiative. We worked together for years, and remain close today.

By 2006 the Texas ranking data described El Paso as a superior system of care. It held that standing until I left in 2011 to lead a system in crisis in Utah.

The Dyad Approach — Valley Behavioral Health, Salt Lake City, Utah

When I arrived in Salt Lake City I was struck by the beauty of the place — and by the state of the system. The contract Valley had built its entire financial, clinical, reporting, and compliance design around had been awarded to Optum, and the organization's future was deeply uncertain.

I came in known for the public advocacy I'd done in El Paso — pressing for more funding and accountability. The Valley board hired me in 2011 to do the same work in Utah.

The first years were hard. We faced insolvency inside my first quarter, locked into a state pension system that made our cost structure unsustainable. I had to find a way out of the Utah Retirement System, and after two legislative sessions we did. It was the best and the worst accomplishment of my career — a perfect Rubik's-cube problem. Leadership congratulated itself on the exit, and at the same time we lost the ability to remain in the state pension; many stakeholders thought it was a terrible mistake. Here the financial quadrant had to prevail, because no reimbursement rate would ever have covered that cost.

By 2016, Valley wasn't improving fast enough to keep pace with an exploding regional economy, population growth, and the infrastructure strain that came with them. We faced shifting reimbursement designs and regulatory expectations, and an ambitious strategic plan aimed at a fully diversified, integrated community healthcare company, with expansion into Idaho and Arizona. Trends across all quadrants were favorable — but not steep enough to secure a durable competitive edge. That was a brutal truth to accept, and we started making big changes.

We rebranded 500,000 square feet of building space. We took annual revenue from $85 million down to $45 million and back up to $75 million on new business lines. We built a sophisticated data infrastructure, sharpened community education and marketing, and installed a state-of-the-art call center with software that enabled chat and web interface. We rebuilt human resources and absorbed massive turnover after the pension loss. We added service lines year after year, diversified funding streams, vertically integrated pharmacy and lab, and completed a successful EMR conversion.

When we added CRM and Peakon to monitor employee and stakeholder feedback, we found rich room to improve. We doubled down on the quadrant approach and, to bring clinical care on par with the best in the industry, elevated new leaders and added a dyad design.

The "dyad" in hospital administration pairs an administrative leader with a physician — closely partnered, sharing decisions, aligned to the same goals. We modified it for community health and human services, splitting the pairing between "business-oriented" and "client-centered" skill sets. Wake up every day obsessed with only one of those and you'll likely do neither well. At the executive level we built a dyad-structured, quadrant-based, feedback-loop learning design. On-site licensed leadership was retitled "Attending Clinicians" — the unit experts on everything clinical. We worked to reduce caseloads and strengthen training and supervision.

As of this writing in 2020, Valley shows:

The dyad approach, on a solid platform for organizational learning, lifted Valley into elite performance across the quadrants and secured its standing as a leader.

CODA (2026)

Originally published September 2020. The section below was added in 2026.

What the years after taught me

When my Valley contract wrapped, my health needed the break and I took it — ten months touring the country's rail-trails. Then a small Montana nonprofit, fresh off a full executive transition, reached out, and I went to work.

I walked into a great mission under severe financial strain, led hard, and lost that one. Montana is where I found the edge of my own method. I diagnose structural capacity now — in the first ninety days, before I commit.

I'm still doing this work — the complex turnarounds, now as a fractional or interim leader rather than a permanent CEO. The method is the same one these pages describe.