Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Phoebe Ministries

Name of Innovative Program: 
Person-centered Community Care Teams
Sponsoring Organization
Phoebe Ministries
Name of Innovative Program Lead: 
Kelly O'Shea Carney, Ph.D.
E-mail Address of Innovative Program Lead:
Physical Address of Innovative Program: 
1925 Turner Street, Allentown, PA 18104
Project Description: 

Person-centered Community Care Teams represent an exciting shift in how behavioral health services are employed in long term care settings. The traditional model consists of bringing a behavioral health consultant into the facility to provide treatment on an individual, as-needed basis. In this way, behavioral health is seen as an outside service provided by a specialist. The Community Care Team model imbeds behavioral health into the long term care setting by placing a psychologist or licensed clinical social worker onto a team with direct care staff working together on an ongoing basis. The interdisciplinary team meets on a weekly or biweekly basis, and consists of members from nursing, community life and dietary staff. The behavioral health professional facilitates the team, providing structure, leadership and encouragement. S/he provides education and training on behavior management, mental health issues, communication skills and intervention strategies. This represents a culture change within long term care that infuses a behavioral health mindset into the facility, empowers direct care staff in being responsive to the behavioral health needs of residents, fosters a truly person-centered approach, and results in a number of positive outcomes for residents, staff and the organization.

Creativity and Innovation: 

The success of this approach lies in infusing a behavioral health mindset and skill set into LTC settings. Recently, there have been dramatic changes in the populations served within long term care (LTC). Medical acuity levels are higher, functional levels are more compromised and the majority of residents present with cognitive impairment and/or behavioral health diagnoses. Addressing the complex needs of residents requires coordinated, integrated care with an awareness of the psychosocial needs of the individual. However, LTC settings have traditionally been dominated by a medical model with behavioral health expertise either absent or operating outside the facility, leaving the psychosocial needs of residents under-addressed. 


The Community Care Team model reverses this trend by fully integrating behavioral health care professionals into LTC settings as clinicians and leaders. They provide direct care services, education and leadership within interdisciplinary teams that address the behavioral, psychological and social needs of the individual.


The Person-centered Community Care Team model was developed as part of Dr. Kelly O’Shea Carney’s Eldercare Method, which has been used in Pennsylvania for over fifteen years, and has been referenced by the Centers for Medicare and Medicaid Services as a best practice. In this regard, the Eldercare Method has been recognized as an effective approach with demonstrated leadership in improving care for long term care residents. In 2014 under the direction of Dr. Carney, Phoebe pilot tested Community Care Teams in four of its long term care facilities. Phoebe expanded the pilot and currently has a total of nine teams operating among the four facilities, serving residents in personal care, skilled nursing and memory support/dementia care. It is our goal to measure and evaluate the replication, implementation and outcomes of each team in order to share the model with other behavioral health clinicians and long term care organizations.


Phoebe Ministries is committed to the continuation and expansion of its Community Care Teams. The behavioral health professionals who lead the teams spend half of their days seeing patients under the traditional fee-for-service model and the other half providing consultations paid for by the facility. The model results in cost offsets that mitigate the cost to the organization. Offsets include reductions in the use of psychotropic medications, staff injuries, staff turnover and psychiatric hospitalizations. These cost offsets, in addition to the enhanced marketability of the organization as providing integrated behavioral health care, have made the model sustainable in the facilities served. The Centers for Medicare and Medicaid have implemented a nationwide initiative to reduce the use of psychotropic medications to address the behavioral needs of nursing home residents in favor of person-centered care and behavioral interventions. This will require new strategies and models of care like Person-centered Community Care Teams.


Phoebe Ministries has tested the implementation and replicability of Person-centered Community Care Teams across four of its facilities in multiple care settings, including personal care, skilled nursing and memory support/dementia care. Each of Phoebe’s facilities is unique in the socioeconomic make-up of residents, physical plant, geographic location, and to some extent the workplace culture. As a result, we have experienced implementation in a variety of settings each with its own unique circumstances. Throughout the process, the conceptual model has evolved and policies, procedures and documentation practices have been refined and standardized. We have developed an implementation manual and believe that the program has the potential to be effectively duplicated by other long term care organizations.


Documented outcomes have included reductions in falls, use of psychotropic medications and challenging behavioral expressions. We have anecdotal and quality improvement data for the following outcomes, but need to gather more consistent evidence over time. Outcomes related to residents: the frequency and severity of problem behaviors; and increases in quality of care and quality of life. Outcomes related to staff: increased understanding of behavioral health needs among residents, collaboration with team members and enjoyment of work; improved skills in responding to challenging behaviors; enhanced relationships with residents; and a person-centered approach to care. Facilities have noted increases in staff knowledge and understanding of behavioral health needs, improved teamwork, higher levels of resident engagement and improvements in resident’s moods. It is our hope that additional data collection will provide concrete support of this model and highlight the value of imbedding behavioral health professionals within long term care as active team members.

Nomination Tags: 
Integration of Behavioral Health and Physical Health
Other Description : 
Integration of behavioral health into long term care