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Susan Partain

Manager, Communication Projects, National Council for Behavioral Health

Whatever it Takes: Strengthening Continuity of Care in MHA Village

October 23, 2014 | Integrated Care | Comments
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This post is the second in a series profiling National Council member organizations who have been recognized for practice innovations in our quickly shifting healthcare environment. The first post featured Vinfen. Upcoming posts will feature Henderson Behavioral Health and the Center for Health Care Services.

SAMHSA’s four pillars of recovery are health, home, purpose, and community. Mental Health America of Los Angeles (MHA LA), one of MHA’s larger chapters across the country, works with the individuals they serve (referred to as members) looking at all four of those pillars – asking each if they have a safe place to live? Are they looking after their whole health? Do they have connections to family and friends?

That is the idea behind the MHA Village (MHA LA’s full-service partnership program, similar to the ACT model), which Dave Pilon, President and CEO of MHA LA, describes as a “whatever it takes” approach to serve those with serious mental illness.

The MHA Village, which started in 1990, was recognized in Phase I of Connect 4 Mental Health for its innovations in continuity of care, helping ensure individuals with serious mental illness receive appropriate and consistent care without significant gaps in coverage or treatment quality.

Pilon notes that their suite of services “focuses on the entire quality of life,” and includes care coordination, psychiatric services, supported employment, benefits assistance, and supportive housing.

Continuity of care means a qualitative approach to services, not just on the mental illness, but on all aspects of the person’s life. The continuity revolves around making sure as many of their needs can be met within a particular setting. All staff are trained in motivational interviewing – which Pilon describes as the foundational way of helping people share what they want to get out of services. To reach individuals who may be homeless, Pilon notes that MHA Village employees do a lot of street outreach; or street medicine – including providing integrated primary and behavioral health care services to the most vulnerable.

But continuity of care goes beyond the provision of services. It is about helping people reconnect and feel welcome in their community, and Pilon notes that many members may come to the Village not feeling particularly welcome in the greater community.

“If they don’t feel that they belong, no amount of treatment will make any difference,” says Pilon. “The most important part of this program is the relationship you establish with your members. It is absolutely crucial, it will outweigh the importance of any evidence-based practice.”

MHA LA has a number of initiatives to strengthen these connections, such as a project that brings a primary care doctor into their facility twice a week for those who choose not to access care at traditional primary care facilities. Every Wednesday, they hold a community meeting, including both members and people from the community. Pilon says this meeting is an amazing experience for both the community and Village members, because there’s still a lot of stigma in the community and this helps to break down negative attitudes and discrimination. Meeting attendees get introduced to all the staff; and Pilon notes “it is like Cheers – making sure everyone knows your name.”

Another key aspect of continuity of care is being able to transfer members to lower levels of care as their condition improves. Pilon notes that funding for programs like the Village can be limited, so “you need to make sure that it is only those people who need the services that access them.” Adding, “we need to work against the bias that people will need these services forever, or else we will get a bottleneck.”

MHA LA is exploring how to create more efficient and effective flow.  They start by looking at the people who have the highest needs in the system – maybe a history of hospitalization, homelessness, or incarceration, and measure their progress and needs. MHA Village tracks people’s improvement on a system to recovery scale. In conjunction with other data, such as their involvement in school or being employed, the scale helps MHA LA determine where a person is in the recovery process and looks primarily at their ability to live in a community.

Pilon cautions that providers can struggle with a “family versus flow” paradox – “when they come to the MHA Village, they sometimes tell us that ‘you folks are my family’ – and we’re happy about that, but the fact is, we really want to be a temporary family, we want to be a weigh station to getting them back into the community.”

People can move to lower, less expensive levels of care, but it also needs to be clear that services are still available to them if they need to move up again. “We have to make sure that as they get better, they are exiting our system,” notes Pilon. “It doesn’t mean we won’t always have a part, they may go to our wellness center or another facility, we have involvement in their lives over time.”

Read more about the MHA Village, and the story of member Chrystal Arzola, on NAMI’s blog.

In this next phase of Connect 4 Mental Health (a national initiative led by National Council, NAMI, Otsuka America Pharmaceutical, Inc. and Lundbeck), MHALA will mentor another community looking to accomplish similar successes. Learn more at