Developing and sustaining private
sector involvement are often among the more challenging components of the
systems change process. Public and
private sector systems often have
different interests and may not be
accustomed to working together.
Except for private, nonprofit agencies that contract with governments to provide mental health and substance abuse services, private sector organizations and agencies have not historically been part of the planning or mobilization of the publicly funded service system.
Government officials may perceive that private sector representatives are
unaware of the complexities of serving public clients with limited resources. Those in the private sector may perceive that government programs are unduly constrained by funding and regulatory limitations.
Although recruiting and sustaining
private sector participation in the
systems-change process may present a significant challenge, the richness that results from the public-private interface is well worth the effort.
Define the Private Sector
Public funders of mental health and
substance abuse services may have an overly narrow understanding of the role of the private sector with regard to public services. While the public sector may identify the United Way and local
community foundations, as well as some
national foundations, as key private
sector partners, it may be unaware of the range of additional private sector stakeholders that can become valuable allies in the systems-change process. These stakeholders may include:
- local and regional business associations, including Chambers of
Commerce, trade associations and merchant groups;
- corporate leaders, including chief
executive officers, presidents and other senior staff of businesses with local headquarters;
- community groups, including
homeowner and tenant asso-
ciations and neighborhood
improvement organizations;
- local activist and advocacy organizations, including family and
consumer organizations such as the National Alliance for the Mentally Ill (NAMI) and the National Mental Health Association (NMHA);
- local provider and professional trade organizations, including associations representing drug and alcohol
counselors and mental health
professionals; and
- private insurance providers and
health maintenance organizations.
Alliances between private sector
entities and the publicly funded mental health and substance abuse service
systems may be difficult to cultivate, but the results of these collaborations can be impressive. In Portland, Ore., the substance abuse service system partnered with the downtown business association to mobilize support among local businesses and merchants for substance abuse programs and housing to alleviate the problem of homeless persons with chemical addictions in the center city core.
Local merchants volunteered to restrict the sale of certain beverages. The business association simultaneously raised funds for treatment and housing services. These funds were also used to leverage public resources and challenge local
government to enhance its activities in the downtown area.
The results have been dramatic.
Downtown Portland, once a haven for
homeless persons with chemical addictions, is now a thriving urban core shared comfortably by businesses, residents and tourists, as well as individuals in various stages of recovery from dependence on alcohol and other substances.
Understand the Importance of Private Sector Involvement
It takes time and effort for parties from both the public and private sectors to
develop and appreciate the potential of these partnerships. Seasoned government planners and funders may feel frustrated and defensive as private sector representatives critique system elements that
appear to lie beyond government control or articulate solutions that appear
unrealistic. Private sector parties may anticipate that government funders and managers will lack interest in their
participation or fail to understand their viewpoints.
Yet the perspectives of both public and private sector stakeholders have their own internal logic and validity. The
insights that can be gained from a
collaborative process are remarkable. Working independently, the two sectors often define system gaps and
barriers from a one-dimensional perspective—both in redefining structural
problems that may lead to gaps and
barriers and in determining how to
improve the effective use of services. Working together, public and private
sectors can develop an understanding of system gaps and barriers that is far more comprehensive than either sector could develop on its own.
The private sector can bring new
resources and suggest methods
to develop and implement innovative
solutions by local and regional
governments. The flexibility of some
government programs may be constrained by complex or time-consuming procurement and contracting processes, such as Request for
Proposal (RFP) requirements, while
private sector interest groups may face fewer constraints and can move with a speed and flexibility that is difficult to match in the government sector.
For example, in Seattle, Wash., the downtown business association worked with local government to determine the feasibility of developing a team of “public safety ambassadors.” The working objectives of the team included:
- sensitive and informed community outreach to homeless persons with mental illness and substance abuse problems.
- provision of public information from knowledgeable and reliable persons to assist tourists and
visitors.
Rather than mobilize this service through a government RFP and contracting
process, the Downtown Seattle
Association organized and funded the initiative within months after it was
conceptualized, resulting in the rapid
deployment of more than 40
“public safety ambassadors.”
Promote a Listening Environment
The initial gatherings of public and
private sector interest groups may
challenge the patience of all parties. Government processes often appear complicated. The vocabulary of public funders and planners, filled with
acronyms, abbreviated program
descriptions, policies and regulations, may sound like a foreign language.
Participants may be surprised by the critical candor of some of the nongovernment stakeholders. It is essential that dialogue be conducted with care and
respect for different opinions, styles and organizational cultures.
Promoting trust across and within
public-private sector systems may at first appear to be an insurmountable task. Government programs present an easy target for a public frustrated with the limited capacity for treatment and the on-going, unmet needs of persons with mental illness, substance abuse problems or co-occurring disorders.
Disregard for persons living in poverty and persons with disabilities, characteristics often ascribed to the business
community, may provide a convenient scapegoat for well-intentioned activists and advocates.
Yet public and private interests have much in common. Efforts are more likely to succeed when parties sit down together and address the human
dimensions of the issues being
discussed.
Start with storytelling. Few individuals in either the public or private sectors have not been touched directly or indirectly by tragedies related to mental
illness and/or substance abuse. Frustrations that result from trying to facilitate recovery for persons struggling with these illnesses provide a common
experience from which a shared
language can be constructed. Representatives of the private sector can share the frustrations they have
experienced with both private and
public systems while attempting to
obtain effective services for family members and friends struggling with mental illness, substance abuse and/or
co-occurring disorders.
Public funders and administrators can describe the challenges of
struggling to serve people effectively with extremely limited resources.
Public sector representatives can also
provide their own stories of how they are touched by these issues on a daily
basis.
Sharing and listening to these stories
provides an element of commonality to promote joint efforts for systems change. This dialogue can offer an
expansive view of problems that may be collectively identified and resolved. The candor and honesty of such
discussions can result in an emerging trust from a system or constituency that may have initially appeared remote and unengaged.
Develop Shared Principles
The dialogue between public and private stakeholders should result in clear and identifiable goals and products. Only then can the concrete tasks of identifying and promoting systems change
begin. It may be useful to establish a set of core, shared principles necessary for an improved, expanded system.
The dialogue between public and private stakeholders
should reuslt in clear and identifiable goals and products.
Only then can the concrete tasks of identifying
and promoting systems change begin.
These principles can become the
foundation for collaborative efforts and the commitment of joint resources. The
principles should be concrete and
specific for programs designed to
reduce gaps and barriers and improve treatment outcomes.
For example, in King County, Wash., a broad-based coalition of public and
private stakeholders developed a set of overarching principles to guide their work to enhance services for persons with co-occurring disorders. The group agreed that multi-disciplinary planning and programming—including both
public and private efforts at the state, county, municipal and community
levels—need to embrace the following core principles of systems integration:
- Services should be easy to access and user friendly. Access to needed services should be driven by and tailored to individual client needs.
- Integrated services should be available for clients with multiple problems. Clinical research
indicates that integration of services greatly increases their effectiveness and positive treatment outcomes. These services should include joint planning and implementation of
services among the mental health, substance abuse and correctional systems.
- Appropriate components of the system should be rooted in a harm reduction model. Traditional
abstinence-based models may not be
effective with individuals with
co-occurring disorders, especially at the outset of treatment. Abstinence may be more than a person with a major mental illness is able to tolerate as treatment begins. At the same time, ignoring the existence of the co-occurring disorders is equally
inappropriate. Although abstinence can remain a long-term goal,
treatment of persons with multiple
problems benefits from access to
a full continuum of care, from
pre-recovery services for clients still abusing alcohol and other drugs all the way to clean and sober housing for individuals who have moved
toward recovery.
- Recovery is a long-term be-
havior change process. Recovery for persons with mental illness and/or chemical dependency must be understood as a process that takes time and incorporates stages of change. Significant milestones
of recovery for persons with
co-occurring disorders often must be measured in years, not months. It is
essential to recognize that relapse is a normal part of the recovery
process that must be addressed by treatment systems.
- Opportunities for information
sharing should be maximized.
Although regulatory requirements limit the sharing of information across service systems, individuals with multiple disorders are best served when the mental health, chemical dependency, primary care and criminal justice systems communicate proactively and effectively.
- Blended funding is an effective and efficient means of service and systems integration. Cooperatively designed, funded and managed
services can achieve systems
integration.
Although several of these principles
initially made some participants anxious,
every stakeholder involved in the
process—from both the public and the private perspective—was able to identify their interests within these principles and validate their involvement. As
consensus emerged, stakeholders
recognized that the jointly developed principles were representative of our
inclusive vision of an alternative future.
Obtain Public and Private Investment
Once shared principles have been
identified, the next steps are to design and implement true systems change. Credit for these integrated activities, when shared among all participants, leads to joint ownership of systems-change initiatives. This joint ownership promotes collective involvement and support for the solutions generated. With a sense of shared ownership, stakeholders from multiple systems will be more responsive to requests for the resources required for systems change.
In King County, a broad-based coalition of public and private parties
conceptualized a “no wrong door”crisis triage unit for persons with mental
illness, substance abuse problems or
co-occurring disorders.The unit would focus on hospital and jail diversions to improve treatment outcomes while
reducing dependence on more expensive and restrictive services.
The crisis triage unit carried a price tag exceeding the financial capacity of any individual system. However, the planning process created a high level of joint ownership in the project. When six separate systems contributed resources for the facility, the unit that initially appeared out of reach to any single system was
operational within months.
Acquire Feedback and Expand Consensus
The integration of services and systems to improve services to consumers
requires more than a single event.
Systems integration is a process that
unfolds over time. Each success or
failure provides an opportunity to realign the process. An ongoing evaluation of system-change efforts and programs is crucial to long-term effectiveness.
Resources for the evaluation of pilot
efforts and integrated programs are funds well invested.
As inclusive as involvement in the planning process may have been, every stakeholder has a larger system of peers, colleagues and supervisors to whom they must report. Reaction to information shared beyond the core group will
improve future discussions. An ongoing
process of activity, feedback,
evaluation and planning will promote more effective systems change efforts.
For example, when the crisis triage unit opened in 1998, the program was
reviewed and evaluated on a regular
basis. Staffing configurations were
adjusted to maximize program effectiveness, and community resources were shifted and modified to meet the needs of persons being discharged from crisis triage services.
Each group of stakeholders brings unique perspectives and methods to conceptualize problems and solutions, and new strategies to secure available resources.
This material was prepared by David M. Wertheimer, M.S.W., M. Div.,
Service and Systems Integration
Administrator for the King County, Wash., Department of Community and Human Services. For additional
information on this topic, contact him at davidmwertheimer@aol.com or at (206)726-0102.
