There are 2 approaches for understanding organizational response to changing environmental demands: 1.

adaptation of the organization to meet institutional expectations and/or 2. environmental selection of organizations that conform to institutional expectations. Mental health care organizations exist in complex, turbulent, fragmented environments Under conditions of adaptation, managers take amore proactive role toward the environment and seek to make needed structural changes within the organization in order to ensure continued organizational survival. Hannan and Freeman(4) argue that, for the most part, organizations are seldom able to make needed changes (they are subject to strong inertial forces), new organizational forms replace those that are no longer in accord with changed environmental conditions, and hence organizational selection is the more common process.

The Continuing Care Division (CCD) was one of the Robert Wood Johnson (RWJ) Demonstration Sites There are two stories that emerge from this case study: a broad story about how mental health organizations are subject to processes of organizational selection as well as adaptation, and a second story that focuses upon the successful strategies used to implement the major structural changes and to ensure continued organizational survival. CCD now must face the problem of organizational inertia because the existing structural form is legitimated by the environment, and internal organizational structures have become relatively fixed and complacent. In order for the organization to "hold onto success," management must meet the challenge of maintaining the original vitality and openness to change, characteristic of the early days of program initiation. In managing success, administrators of mental health care organizations must take a proactive stance toward the environment and ensure that the organization is able to adapt to constantly changing environmental conditions. -Community-Based Care and the RWJ Foundation The Robert Wood Johnson Foundation responded to this issue by providing funding for a nationwide demonstration project. The major purpose of the funding was to provide housing; centralize clinical, fiscal, and administration authority; provide continuity of care; develop a wide range of services; and change financing structures away from entitlements.

-Changing Models of Care CCD was much like other community mental health centers (CMHCs) in the state: focused primarily on acute, adult outpatient care with some provisions for emergency psychiatric care. The program to provide care to the "chronically mentally ill" (as consumers were referred to at this time) was called "New Directions" (a euphemism because participants recall lacking any direction). New Directions was based on a biomedical model in which medication was the primary component. there was a great deal of frustration and turnover, negative contact with advocacy groups, and few, if any, indicators of success -Environmental Threats to Existing Organizational Forms New Directions faced a series of challenges resulted in the emergence of a new organization form. New Directions did not have a positive public image; it also had poor community relationships and weak inter organizational ties with other agencies providing social services. There was a general perception that the mental health professionals possessed an uncaring attitude. The legitimacy of a mental health center was further weakened by a much-publicized incident in which a former client murdered his mother. This galvanized local grassroots advocates to push for better services for those with chronic mental illness. In part due to the perceived inability of the public mental health sector to provide adequate services and in response to a more general political preference for privatization, the County Area Authority implemented a plan whereby mental health services were contracted out to a private hospital system. Consequently, pressure also was placed on the Area Authority by the Alliance for the Upon receiving the RWJ grant, New Directions was replaced by the CCD, which was initially under two organizational authorities: the county and the private hospital. This situation ended in 1988 when the CCD was returned to the county and placed under the Area Authority, -Emerging Mission and Functional Program In general, the model of care implemented at the CCD can be characterized in terms of biopsychosocial rehabilitation. With this model rehabilitation, the consequences of mental illness are the focus of care. Medication still is emphasized and is provided in order to deal with the overt manifestations of mental illness; however, psychosocial rehabilitation deals with the stigma, lowered self-esteem, and loss of community support that are all consequences of mental illness. Hence a wide variety of specialized programs are offered as well as medication. -Strategies for Implementing Change -Restructuring Organizational Forms 1- The defining structural change at the CCD was the introduction of case management and the resulting redefinition of work roles and organizational structure. Case managers are referred to as PRCs (psychosocial rehab counselors) and provide psychosocial rehabilitation in addition to the medication dispensed by doctors and nurses. PRCs work to ensure that the basic needs of clients are met, including housing, income, clothing, food, and work or some other regular activity.

Initially, there was a great deal of resistance from staff to the idea of case management. y Existing staff were mostly social workers, and the title of case manager represented a de-skilling of work roles and a corresponding loss of occupational status and prestige. The changeover to the public hospital in 1986 also raised legitimate fears about seniority, benefits, and retirement. The solution was to allow staff to collaboratively redefine their own job titles and descriptions (hence the use of the title psychosocial rehabilitation counselor as opposed to case manager). A retreat was held to unfreeze old paradigms, to educate staff to the necessity of change, and to orient staff to the new program philosophy. Further, frequent opportunities for more discussion of the process were provided, allowing for the enhancement of a sense of effective professionalism among staff and contributing to a sense of shared mission. The success of the reorganization of work roles and organizational structure was due, in part, to the willingness of management to foster a collaborative work environment characterized by open communication, mutual trust, and confidence.

External y Resource Acquisition In addition to internal structural changes, the CCD had to re-establish legitimacy with the external environment. The RWJ grant gave the CCD public visibility, but the actual amount of resources provided was not extensive and administrators had to secure local sources of funding in order to develop the model of care described above. The CCD was able to replace the RWJ monies (about 14% of its operating budget) with local Monies. In moving beyond implementation to stabilization of organizational form, the CCD assumed an increasingly proactive and innovative stance toward the environment by developing new services, forging ties with community agencies, and securing funding.

Current resource shortages have challenged all public agencies; likewise, the CCD has had to struggle to secure the resources to maintain existing services in the face of growing client populations and rising costs. In response to these various demands, the CCD has engaged in active community outreach, education, and collaboration. Contact was increased with the local AMI group, and various local community boards and staff collaborated with a Citizens' Advisory Committee comprising consumers, advocacy groups, and citizens at large. One strategy is to sensitize community groups to the needs of consumers. The CCD produced a 10-minute video, depicting staff and consumers who shared their viewpoints and experiences with service delivery.(18) Night classes on illness education also have been offered (although not well attended) and a monthly newsletter is distributed to the wider community. In short, for their continued survival, mental health organizations must work to ensure that they are regarded as legitimate (by being successful or working hard to provide needed services) by the institutional environment in order to secure needed resources.

-New Threats to Organizational Success: Inertia As the organization has grown in size and in the number of its specialized services, CCD's communication between dispersed sites and specialized services has become an issue of concern. The trust between groups that is naturally fostered with frequent communication is threatened as work groups become more isolated from each other and provide different service offerings to various target groups. It is easy for administrators to lose touch with the informal culture and incentive systems of specialized units and work groups. The solution to the problems of compartmentalization and specialization is to again encourage active involvement and contact between all layers and segments of the organization. The goal is to maintain mutual appreciation for each group's needs, concerns, and perspectives. This can be accomplished by developing meeting protocols that stimulate active participation and communication, and increasing staff involvement in monitoring and planning of services. At the CCD, regular team staff meetings are held as well as monthly staff meetings between program staff who do not normally directly interact (i.e., clubhouse staff with case managers). Both short-and long-term planning meetings are held regularly. A suggestion box is used and ideas are discussed at staff meetings. Ongoing training opportunities and public recognition of work well done via symbolic rewards also can maintain the high standards of professionalism needed to hold on to success. The CCD has developed an Employee Incentive Plan whereby staff recognize each other for outstanding performance via the aforementioned suggestion box. Regular staff recognition events also are held. Continuous feedback and communication of the qualities valued by the organization is needed to maintain a can-do symbolic image of the organization. - A second major problem is the ability (or inability) of the organization to meet changing environmental conditions and demands. Community groups call for alternatively more decentralized care and community outreach, as well as more restrictive, supported environments for consumers. Mental health organizations somehow must meet these conflicting objectives; the CCD has done so by increasing the number of satellite programs and staff members who serve in outreach positions and by increasing its in-house programs (partial hospitalization and crisis stabilization). Case managers also were stationed at nearby homeless shelters in order to enhance interagency coordination and to be more accessible to clients. Another environmental demand is increased consumer advocacy, that is, increasing the opportunities for consumers to take an active role in providing treatment. The CCD has responded positively to these developments and has actively promoted the involvement of consumers on decisionmaking boards and committees. Such efforts need to provide consumers with real opportunities for empowerment and involvement in the organization of services.