This issue of The Change Agent’s TOOL BOX describes various strategies for sustaining the momentum required to make change occur at both the system and service levels.
Even with the right players at the table and the resources identified, systems change initiatives can falter if the change process is not paced comfortably enough to promote ongoing participation and quickly enough to overcome resistance and prevent stagnation. Change
activities must also be punctuated with opportunities for both “quick victories” and long-term projects that only yield
significant results over time.
Virtually every stakeholder in every
system is familiar with the trap of endless processes that produce thick piles of well-intentioned reports but that never
really get anything accomplished. It is invariably true that with each new study of a problem, a system learns more about the nature of the issues involved and how to best solve them. This is particularly true where problems and issues cut across multiple systems. There will
always be another perspective to
consider. Doing “just one more study” can also become a convenient excuse for avoiding action; resistance to change can be easily cloaked in the robes of
research and review. However, at some point it becomes necessary to declare that enough information has been
gathered, that no more studies are needed and that the time for concrete action has arrived.
Helping to identify when this point has been reached and to pivot the system from contemplation to action is a key responsibility of the systems change agent. The change agent must not only be skilled at the processes required for bringing stakeholders together and
finding common ground for problem
definition, but he or she must also know when there has been enough process and discussion and how to move
risk-averse or overly cautious players from contemplation to action.
Setting goals and deadlines for taking concrete steps is essential. Stake-
holders should agree at the outset on
the timelines and event horizons of
their collective work, and they should decide in advance on when the
mobilization of innovative, integrated
services will begin.
Implementation of systems-integration activities will fare better when they are identified as core components of a system’s basic business rather than a specialized set of activities that funders and managers will get around to when they finally have the time. In many
government and non-profit provider
systems, that “extra time” for systems-integration efforts rarely, if ever,
materializes.
In short, unless the systems-integration agenda is woven into the basic business agenda, it will probably never happen. Senior system managers may find it
useful to place integration activities into the work plans of those who are responsible for program design, implementation and management.
Achieve Early Victories
Promoting integration and systems change is hard work. If all of the goals and objectives identified in an integration work plan envision changes that will not have an impact on the systems
involved for a long time, the energy and motivation required to make change
happen may not materialize.
Participants in the change process need to know that what they are doing is making a difference. Creating an integration plan that facilitates a series of early “quick victories” can be very
helpful in increasing motivation, participation and the energy applied to the change process.
Achieving these early victories requires participants and leaders in the integration initiative to identify programs and tasks that reflect the vision of an
integrated approach to problem solving that can be accomplished with relative ease and in a comparatively short period of time. A number of examples from King County, Washington, will help to illustrate these types of smaller, incremental yet highly visible integration interventions.
Mental Health Enhancement for Detoxification Services. Adding mental health staff to the local alcohol and drug detoxification facility greatly
increased the willingness and ability of the program to accept persons manifesting a higher level of mental health symptomology—including suicidal
ideation. This change was not hard to
accomplish and required reassignment
of the resources needed for less than three full- time positions. Yet the tangible results were remarkable.
The feasibility of blending resources was demonstrated. Managers in the alcohol and drug system were reassured that systems integration did not mean a “takeover” of the chemical dependency
system by its larger mental health sibling; resources and staff were actually moved from the larger to the smaller system. Significant system savings were realized. Suicidal individuals with substance-
induced mood disorders who, in the past, would have been inappropriately placed in more expensive psychiatric inpatient settings could now receive less costly and more clinically suitable detoxification
services. Linkages at the back end of detox to residential or community-based drug/alcohol treatment could be more easily facilitated.
Jail-Mental Health Information Linkage. Creating an automated data linkage between the jail and the mental health system provided real-time notification
of client incarcerations to mental
health case managers. For years local jail officials had complained that case managers in the mental health
system were slow to respond to clients who were arrested and booked into the county jail. In reality the mental health providers had no reliable way of
knowing when these incarcerations were occurring; few clients call their case managers to report that they have been booked.
Initially, jail officials requested that the mental health system provide them with a list of all “enrolled” mental health
clients. Although confidentiality statutes prohibited this type of information
exchange, it was possible for the jail to provide the mental health system with
a daily list of all bookings. (This
information is a matter of public record.)
Utilizing less than two weeks of
(expensive) information system staff
programming time, the mental health
system was able to work with the jail to receive this information electronically, compare the names provided with those in the mental health information system and route electronic notification to the responsible case managers at each provider agency. The result of this modest effort was revolutionary. Case managers were now being informed that clients had been incarcerated within 24 hours of booking.
Cross Agency System Training.
Creating a regular opportunity for training on accessing mental health and
substance abuse services for youth helped to make the youth treatment
system more navigable for all involved. For many years, providers of services to youths in a variety of settings including schools, community centers, youth
detention and elsewhere had indicated that the mental health and drug/alcohol treatment systems were complex, difficult to access and not user-friendly to youths and their families.
Working in partnership with multiple
systems, the mental health system
in King County developed a quarterly
training called the Cross Agency
System Training (CAST), which is open to all interested parties including
providers, advocates, family members and consumers. The 8-hour CAST
curriculum is designed to give participants an introduction to the
range of services and opportunities
available to youth in need of a variety of supports. Presenters from different
systems provide information about how their respective systems operate and how to access assistance. Expenses
are minimal, enabling the training to be
offered free of charge.
High Utilizer Staffing. Providing a
regular forum for multi-system case
conferences and consultations on clients who are using large quantities of the most expensive and/or restrictive services gave King County opportunities to
create coordinated case plans for
challenging clients and to promote
interdisciplinary cross training among multiple disciplines. Consultations are regularly held for frequent users of both detoxification and crisis triage services. When providers from multiple systems sit down to review the specific details concerning individual clients, coordinate
and consolidate treatment plans and
develop a consistent response to
client needs across multiple agencies,
the impact on client recovery can be
dramatic.
Co-Occurring Disorders Breakfast.
Offering a monthly breakfast meeting for line staff and clinical supervisors who are serving clients with co-occurring
disorders offered an excellent vehicle for sharing accomplishments, frustrations and emerging best practice models in the field. In King County, this breakfast meeting started informally and has
become one of the best attended and most popular activities in the systems-
integration arena. The breakfasts have attracted the attention of local
and state mental health and chemical
dependency system managers, who have attended the meetings to learn
more about what systems integration actually means and looks like at the
direct-service level.
Create Strategic
Leadership Plans
These types of systemic changes may not only take more time to accomplish, but they may also engender more
intensive political and fiscal conflicts. As the work becomes more challenging and potentially more threatening to stakeholders who are worried about the implications of change on their particular
system or interests, it is essential for the change agent to maintain the partnerships that have facilitated the change process thus far. It may also be of value to add to and enhance stakeholder
participation as systems that have not yet been at the table (but need to be) are
identified.
As the systems-integration process moves closer to tangible changes at the structural levels of the system, reluctant or cautious participants often disapper from stakeholder advisory groups and associated planning efforts. This is
a dangerous time for the systems-
integration initiative.
As key players disappear, it may seem that one or another system is dominating or controlling the change process.
Stakeholders who are resistant or
reluctant may begin to point fingers at the process itself and suggest that what was envisioned as a partnership among equals to enhance outcomes for persons with co-occurring disorders has become a “takeover” of the service system and its resources by one key player.
If this seems to be happening, it may be useful for the change agent and the key stakeholders to pause in the process to take stock and implement preventive or corrective measures to enable the change process to continue to flourish. Create a “strategic leadership plan” to keep the process and players on track toward the collectively identified vision that was established at the outset of the integration initiative. Activities that may be undertaken as part of the leadership plan include:
- Management or leadership retreats involving senior players from
all involved systems that can
help to reestablish both the trust
and participation necessary for
successful systems integration
initiatives;
- Public forums or events at which consumers, family members and advocates have the opportunity to remind funders, planners and
providers of the need for a system that makes sense from the
perspective of the person with
multiple problems; and
- Conferences or workshops for
providers that focus on best
practice models for persons with co-occurring disorders.
To be successful, systems-integration processes require ongoing refinement. The type of attention required is
defined by the level of maturity the change process has achieved.
This material was prepared by David M. Wertheimer, M.S.W., M. Div., Principal
Consultant, Kelly Point Partners,
a Washington state-based human services consulting firm. Previously, Mr. Wert-
heimer served as 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.
