To build effective coalitions, highly
diverse constituencies often unaccustomed to working together must learn to comfortably share the same table. Consumers, family members and
advocates as well as providers, administrators and funders from the mental health, substance abuse treatment and criminal justice systems need to work together for the goals of systems
integration to be realized.
Laying Foundations for Effective Coalitions
The earliest efforts to build cross-system coalitions to promote systems change in King County, WA, were something of a disaster. Representatives from provider agencies in the mental health and substance abuse treatment systems were invited to meet for an open-ended dialogue on gaps and barriers between and across the two respective systems.
Each group brought a preconceived set of notions about the other to the discussion. The mental health team members looked at their drug/alcohol colleagues and thought they saw a group of under-trained, abstinence-oriented individuals. The substance abuse service providers looked at their mental health colleagues and thought they saw a group of
over-trained enablers.
Neither group had an image of the other that was remotely accurate. The
assumptions each group made were rooted more in their own professional fears and biases than in reality. It took several meetings for the group to become comfortable and relaxed enough for meaningful dialogue to occur. Several years later, a third party was included—the local jail system.
Until parties from all three systems were included, little meaningful dialogue could occur. In addition, until these core
service and justice system representatives were joined by other key stakeholders such as consumers, advocates, family members, administrators and funders, there were minimal incentives or
motivations to actually getting anything accomplished.
The work required of a coalition with a systems-change agenda cannot be done in isolation by one system or group of stakeholders. When this occurs, the
rejection of the product by other stakeholders and systems is virtually
guaranteed. If the work and product are defined and crafted by multiple systems and stakeholders working together, the joint ownership of the outcomes is of great value in promoting real change.
Assembling Key Stakeholders
Defining who should participate from each system, the nature of the
“membership” and the process of a
systems-change initiative are critical steps in the coalition-building process. As suggested by the King County
example, prior to creating a coalition,
focus groups among key constituencies can help with the construction of a
working group and to build a sense of expectation among stakeholders.
“Buy-in” to the process is enhanced when it is understood that involvement in the effort from its most preliminary stages is essential. Before promoting cross-systems dialogue, it may be
useful to invite key constituency representatives to separate meetings to
describe the nature of the problems, gaps and barriers that confront their most challenging, multiple-problem clients.
It is important, at this point in the
process, to identify a sponsor for your efforts who is highly placed, respected and influential across multiple systems to influence participation in a collective planning process. County executives, governors, or health and human service and correctional commissioners are
examples of this type of leader. Although this individual does not need to be
involved in the activities of the group on an ongoing basis, the leader can help to set the overall tone and agenda, request regular updates on the progress of the effort and meet periodically (annually is often sufficient) with the group to provide new motivation for the work that lies ahead. This individual also becomes the recipient of work products and recommendations from the group.
Defining a Role and Getting Started
As key stakeholders from multiple systems begin to actively discuss the formation of a working group, it is important to define clearly the role of the working group and to whom the group is
accountable. As policy-level decisions in many systems lie with elected or senior- level appointed officials, an advisory role for the cross-systems integration work group is often the status that elected and appointed officials are most willing and able to accept.
Assigning an advisory role, however, does not mean that the group is without
authority. The more representative and
inclusive an advisory body becomes,
the more weight may be given to its
recommendations. An advisory group that delivers a consensus reaching across all constituent systems is extremely difficult to overlook.
Inclusiveness is an important goal in the formation of a systems-integration work group. Outreach to key stakeholders not initially identified is an important—and often ongoing—task. Membership should not be limited or exclusive.
If representatives from another system begin to miss meetings, it is important to
encourage continued participation. It is essential to have representation from
consumers; advocates; family members; and underserved and often marginalized populations, such as ethnic and cultural minorities; persons who are or have been homeless; and members of the gay, lesbian, bisexual and transgender communities. In order to sustain membership from a representative group of stakeholders, meeting times may need to be adjusted to accommodate those who are not paid to participate.
Early morning meetings often work well, especially when food is provided. Late afternoon or early evening meetings are an alternative but may attract fewer participants due to family responsibilities and end-of-day exhaustion. Holding meetings on a regular (e.g., monthly)
basis, at a set time and location, helps to establish a rhythm and a sense of
stability for the group.
Leadership of the group will be most
effective if it is invested in individuals who are not identified as participants with overriding special interests. In King County, for example, the local Systems Integration Advisory Council (SIAC) is co-chaired by representatives of the
public mental health and alcohol and drug advisory bodies. These bodies
comprise community volunteers who are nominated by the County Executive and
approved by the County Council. Each of the advisory bodies selects a
representative to the SIAC who serves as a co-chair. This allows for a process that is controlled by the public rather than by representatives of a bureaucracy, and it also ensures that no one system dominates or controls the process.
Effective and sufficient staffing is
critical to the success of a systems integration coalition. Specific individuals with the skill set required to accomplish core duties should be assigned to the work group. This staff is responsible for
recruiting group members, providing
announcements and minutes of regular meetings, conducting group-related
research and other tasks as assigned
and providing general support and
motivation. These tasks require a
substantial time commitment and will be most effectively performed when they are
considered a primary component of a job description, rather than an add-on to the work of already overburdened program staff.
Developing a Work Group Charter
There is great value in clearly defining the parameters, boundaries and roles of the stakeholder work group and its
activities. Work groups without charters or other documents that clarify their
position, role, nature of work and the product to be produced will quickly settle into confusion and indecision.
Early on, the stakeholder work group should establish a written record of what it is and what it does.
At a minimum, the charter should include the following components:
- a mission statement;
- a description of the group’s membership;
- how the group is configured, how often it meets, and how it is chaired and staffed;
- topic areas included within the group’s mandate;
- anticipated or expected outcomes;
- how decisions and recommendations will be made and ratified; and
- how the group issues reports and recommendations and to whom the group is accountable.
A work group focused on integrating services across multiple systems should ensure that it prioritizes input from all involved systems and stakeholders,
identifies gaps and barriers in existing systems, develops problem statements and proposes solutions that are inclusive of players from a variety of different
locations within each system.
Beginning a Dialogue
Organizing a systems-integration work group is, in some respects, the easy part. Actually getting down to the tasks
identified in the work group’s charter can be far more challenging. Defining the term “systems integration” may present conflict. Breaking down this core
concept into its component parts may
become a first critical step in the change process. In this context, the component parts of systems integration can be
defined as follows:
Shared Information: Information about programs, services, treatment models
and clients all moves across the
traditional, categorical lines of service
delivery systems.
Sharing of information, planning, clients and resources
is exactly what systems integration is all about.
Shared Planning: Multiple systems
engage in conjoint processes to plan
integrated services for multi-problem
clients.
Shared Clients: Multi-problem clients who traditionally receive services in only one system or receive uncoordinated care in multiple systems are shared by
appropriate treatment systems and treated in a coordinated fashion (e.g., single treatment plans, multi-disciplinary teams, etc.).
Shared Resources: The resources
available to multiple systems are blended and/or shared to ensure that services are
configured in a way that meets the
individualized and tailored treatment needs of clients rather than the needs of the systems or providers offering care.
Each of these tasks is far easier to
describe than to accomplish. Shared planning is challenged by philosophical and language barriers across systems. For example, mental health professionals may be puzzled by the language of recovery—a concept central to the drug/alcohol system. Drug and alcohol
counselors may find the concept of
intensive, wrap-around case management services equally foreign to their
accustomed treatment paradigms and practices.
Sharing clients may make managers and administrators at the agency level
anxious. With scarce resources increasingly attached to bundles of treatment for specific individuals, the sharing of
clients suggests the sharing of dollars at the service level, a practice that may
be interpreted as a loss of revenue rather than enhanced individual client outcomes
and system savings. Similarly,
sharing of resources expands the threat of sharing clients to the systems level.
Policy makers and program managers in government may find the concept of blending resources challenging in an
environment dominated by categorical, siloed funding. Yet sharing of
information, planning, clients and
resources is exactly what systems
integration is all about.
One route to overcoming initial fear and resistance is to borrow from the language of the field of training for cultural
competence. If a culture is identified as something with its own language,
history, beliefs, institutions and practices (with biases and stereotypes about other
cultures as well), then each of the
systems that comes to the integration table—e.g., mental health, substance abuse, criminal justice—represents a
distinct and identifiable culture.
Cultural competence occurs when we develop the capacity to understand,
appreciate and even celebrate the
richness of a diverse cultural environment and develop the ability to function
effectively in a variety of cultural
settings. An integrated system should be one in which a broad range of
perspectives and disciplines function
collectively to create systems that best address the needs of multiple-problem clients.
Developing a Vision
A systems integration work group may be able to work most effectively if its members have a shared vision of what the system could look like if systems-
integration goals are achieved.
Developing a vision statement that speaks simply, clearly and inclusively can
become a central rallying point from which group efforts can emanate and to which they can return for validation of concepts and solutions.
A vision statement should be simple,
concise and clear. It should immediately
engage all parties and provide a familiar sense of “Aha! So that is what we are talking about!”
In King County, the SIAC described above borrowed the concept of “No Wrong Door” from the ACCESS program, the federally funded research project on homelessness and severe mental illness. “No Wrong Door” means that every doorway to the mental health and substance abuse treatment systems is the right door, regardless of a person’s
presenting complaint or what they may need first on their path to stabilization and recovery. It suggests that creating a single doorway to assistance is not the goal because single doorways to treatment systems tend to limit access to care rather than expand it.
“No Wrong Door” became the vision statement and rallying point around which the systems-integration initiative in the county defined what it was trying to accomplish and where it was trying to take the system as a whole. Even though each stakeholder from every system may
not have had precisely the same
understanding of the vision, the concept of “No Wrong Door” provided enough common ground for large-scale “buy-in” to the integration effort.
Getting Down to Work
With a vision, mission, charter and membership in place, the systems-integration coalition can effectively begin to address the difficult tasks of conceptualizing change and making it happen. Keeping to regular monthly meetings, at a set time and location, may help the group to
become an effective clearinghouse for
information, concepts and recommendations under development.
Specific subcommittees and task-focused groups can be created to address concrete tasks, such as:
- creation of models for integrated front-end crisis services,
- definition of best treatment practices for persons with co-occurring
disorders,
- identification of strategies to increase jail access to treatment providers from the mental health and substance abuse service systems, and
- development of proposals pertaining to blending of resources from
multiple systems to enhance services for persons with multiple problems.
As subcommittees and task groups
create work products, the larger
coalition can discuss, refine and
ultimately approve recommendations
related to integration goals.
These recommendations should be
formally adopted by the work group and then forwarded to the policy-
level sponsors. These sponsors then
become accountable to the work group for their successes (or failures) in
implementing recommendations that have been crafted and ratified by a
broad-based coalition of knowledgeable stakeholders.
This material was prepared by David M. Wertheimer, M.S.W., M. Div., Service and
Systems Integration Administrator for the King County (WA) Department of Community
and Human Services. For additional
information on this topic, contact him
at davidmwertheimer@aol.com or at
(206) 914-4475.
