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Case Study #13: Remaking Mental-health Care

The Dallas Foundation fills a gap fast with a nonprofit neighbor

When David Gelbaum offered his $243 million gift to aid current and former military members during the height of the Iraq war (see case 1), getting the funds to groups that could use them fast enough to have immediate impact was a challenge. To involve local experts in targeting grants, Gelbaum’s Iraq-Afghanistan Deployment Impact Fund placed large sums in the hands of community foundations in states like Texas and Florida, with instructions to re-grant the money to particular groups in their states doing good work. In this way, the Dallas Foundation became a conduit for distributing millions of dollars of IADIF money over a period of five years.

Among other achievements, $1.2 million in Dallas Foundation funds seeded a novel mental-health program at a nonprofit hospital near Fort Hood in Killeen, Texas. Thanks to these independent philanthropic resources, Scott & White Hospital has been able to sidestep government bureaucracy and offer nonprofit mental-health services that would otherwise have been unavailable to many of the recipients. More than 28,000 soldiers and military family members have benefited from high-quality confidential treatment as a result.

Sometimes an Outside Institution Can Be Better

When the Dallas Foundation and two other Texas community foundations received money from IADIF to redistribute, the first thing they did was to commission a survey to determine areas of greatest need. In less than two months, they had a list of seven funding priorities. In early 2007, when needs assessments were scant, this information provided the foundations with a useful guide by which to judge proposals.

Mental health was one of the issues that Laura Ward of the Dallas Foundation hoped to address early on. She was concerned, though, that issues of stigma and trust might complicate delivery of services to soldiers and their families. “We knew that getting people to come was a problem,” says Ward. When Scott & White Hospital applied for a grant, however, she thought she might be looking at a solution.

Killeen, Texas, a town of about 55,000, has two major assets—Fort Hood (then home to two full divisions of soldiers), and a Scott & White Hospital (part of a major nonprofit medical network that has served central Texas for more than a century). Matthew Wright, a vice president at Scott & White, notes that Fort Hood functioned as one of the U.S. military’s foremost gateways to the Middle East over the last decade. “There were some wise commanders on Fort Hood around 2006–2007 who realized the uptick in deployments to Iraq and Afghanistan was going to inundate the official military mental-health capacity. They said, ‘We need to reach out to our surrounding community and ask for help.’”

As war-zone rotations of locally based soldiers ramped up, a retired three-star general living in Killeen named Don Jones approached the commander of the Fort Hood medical center and asked what he could do to help. According to Jones, the commander responded, “Well, we have two mental-health workers here for two divisions of soldiers.” Luckily Jones had some experience in this area, including a stint after leaving the military helping the American Red Cross implement its mental-health program in disaster response.

Jones suggested that rather than inventing something new they take advantage of their proximity to the Scott & White Hospital. While the base and the hospital had worked together before—they were, after all, the area’s two largest employers—they had never collaborated on a project as sensitive as mental-health services. A short time after the leadership at Fort Hood approached Scott & White, Maxine Trent joined the hospital to run the new program. She was a perfect match—in addition to being a family-therapy clinician, she was an Army child herself, and a Navy spouse.

By 2008, families at Fort Hood were going through their second and third deployments to Iraq and Afghanistan. Families were “getting barely enough time to catch their breath, and then going through another deployment,” explains Trent. The combination of combat stress and family reset issues created plenty of demand for services.

There were, however, cultural, professional, and financial barriers that discouraged resort to mental-health care. “Soldiers were not seeking help, over concern of what the impact would be on their military careers,” says Jones. “I even found soldiers in Fort Hood who were driving to Austin, Texas, to get mental-health counseling at their own expense.”

Although the Defense Department has recently put extensive effort into decreasing the stigma surrounding mental health, Scott & White realized it faced an uphill battle to overcome the perceived weakness of seeking treatment. To build credibility, the hospital hired therapists who were ex-military or military dependents. “The military ID card and a former rank go a long way in terms of trust,” explains Wright. “And then word of mouth took over.

The hospital also never labeled its offices as “mental-health clinics.” Instead it co-located those services with its pediatric and adult primary-care clinics, so that no individual had to identify as a mental-health patient. Using the primary-care clinics with which many Fort Hood families were already familiar also put patients at ease.

Ward and the Dallas Foundation were impressed by the way Scott & White got around the issue of stigma. “They created a way for people to visit, and taught their physicians to recognize stress symptoms and plug patients right away into mental-health services without it ever touching their record. They already had a captive audience that trusted their hospital.”

Working hard to balance cooperation with the Army with independence on behalf of patients, Trent earned the trust of leaders at Fort Hood. She understood the military well enough to know that commanding officers are responsible for all aspects of the lives under their command, and that ceding some of that to an outside organization is a risk. The response was to “set up the right channels for sharing critical information.” In situations where patients posed a threat to themselves or others, base leadership would be involved. Otherwise, the Army would not have access to details of those seeking help at the hospital. Once comfort was established, the Army medical center began referring patients to the hospital, and hospital staff were allowed to visit Family Readiness Groups and other support organizations on base to spread word about their services.

Restructuring Medical Care through Philanthropy

The stigma sometimes attached to mental-health services can make for difficulty not only in seeking help, but in paying for it as well. Sometimes, says Matthew Wright of Scott & White, “the obstacle to mental-health treatment is the diagnostic code. It will determine whether or not insurance will pay for the procedure.” Sometimes a person feels stuck between a rock and a hard place. “If I’m under stress and need someone to talk to, and I self-pay, there’s not a problem. But most of us can’t do that. If I have a diagnostic code that allows insurance to pay for it, that means it goes on my service record and I get diagnosed with a problem.”

How does Scott & White get around this dilemma? Via philanthropy. “If we use philanthropy to pay for it, the only thing we need to keep track of is the patient count, and measurements of success,” says Wright.

The hospital takes inventories before and after counseling to measure success. “If what the patient wants is relief from hyper-vigilance, then we use clinical measures to assess your hyper-vigilance on the first session, on the third session, on the sixth session,” explains Trent. “We use treatments supported by clinical data, and we compare our progress to that. So we’re measuring our interventions the whole time.”

“We have two mental-health workers here for two divisions of soldiers,” said the commander. Philanthropy filled the gap.

Relying on philanthropy rather than insurance or self-pay also frees the hospital to run the program very flexibly. For instance, instead of paying its therapists per patient-hour of treatment, as most clinics do, the grants from the Dallas Foundation and other donors allowed Scott & White to pay therapists a salary. Then they “see as many people as they ethically and clinically can. If this person needs 15 minutes, give them 15 minutes. The next person who comes in may need an hour and a half; give them an hour and a half,” say Wright. By changing the economic model, philanthropy allowed a given amount of dollars to go further and treat patients more effectively.

The results were stunning. The hospital expected to see 900 patients in their first 18 months; instead it treated 1,800 patients in the first four months. In 2009, when a disturbed Islamist serving at Fort Hood killed 13 people and wounded many more, the hospital was there to provide support, providing over 600 appointments to those affected by the event. Thanks to timely philanthropy, Scott & White helped a total of more than 28,000 patients during the period when deployment stress was most severe at one of America’s largest military bases.

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