Apollina Smith’s Amazing Recipe for Upside Down System of Care Cake
October 07, 2016
October 07, 2016
Morning Zen Guest Blog Post ~ John Franz and Patricia Miles ~
Blame it on the Wine
As Apollina Smith sat down at the cluster of ancient green, rubber-topped Steelcase tables that had been shoved together for her meeting in the upstairs conference room at Kenyon County Human Services she asked herself, not for the first time, why she had let Cassie Nightingale, the new county executive, talk her into coming back to the county to once again become Director of Human Services. She had been there and done that and had the scars to prove it.
Thirty years ago she had been a unit supervisor and was part of a team that put together the county’s first Wraparound Project. Ten years later she had become the director of the department and wrote the grant proposal that funded the county’s first system of care for families with children who had severe emotional disorders. Ten years after that the great recession hit Kenyon and efforts became focused on efficiency and cuts. Apollina fell on her sword by cutting management rather than line positions. The focus on efficiency and cutbacks continued and eventually placements started creeping up until Kenyon County experienced a full force explosion in out-of-home and out-of-county foster placements and even out-of-state residential placements.
From there Apollina had drifted, heart-broken at what was happening to children and families in her county. For a while, she worked as a consultant. Finally, she took a job managing a child welfare department in a county in Minnesota and assumed that was where she would retire.
But then Cassie, who had been a young and green county board member when Apollina was let go but had grown into a thoughtful and determined change agent, called. Cassie invited her to return to Kenyon to restore stability to the Human Services Department, which had gone through another unpleasant reorganization. As much out of curiosity as any thought that she might take the job, Apollina agreed to at least talk it over.
When she came to town for her initial interview, Cassie took her out to lunch at the Feed Mill, a new restaurant appropriately installed in a restored 19th-century feed mill at the edge of town. The two women shared a bottle of Sauvignon Blanc and a couple of plates of bruschetta on the back deck of the restaurant, looking out over the Kenyon River as it slowly snaked through bottom land thick with goldenrod and milkweed.
“This would give you the chance to finally put your own stamp on how services get delivered in this county,” Cassie had said.
For a few moments, Apollina tried to think of a way to respond to her young friend’s enthusiasm. She didn’t want to sound snarky or condescending, or as old as she sometimes felt. But she had been through so many reforms and reorganizations, innovations and disasters, and just plain ups and downs, that she wasn’t sure she had it in her to take on another challenge. She was no longer under the delusion that there was one, secret, exactly right way to do things. On the other hand, she had also learned the hard way that there were definitely some ways to do things that should be avoided if at all possible.
Finally, undoubtedly influenced by the wine, Apollina had answered, “You know, Cassie, I’ve put my own stamp on a number of things, including a couple of marriages that could have gone better, so I think another option might be to find a way for the people we are trying to help put their stamp on how services get delivered.”
Apollina had hoped that would be enough to knock her out of running for the job, but instead it ignited Cassie’s enthusiasm. A few months later she found herself back in her old offices in Kenyon and preparing to chair her first interagency meeting since her return. Surrounded by well-meaning managers from all of Kenyon’s helping organizations, Apollina wondered why she hadn’t taken her social security and what was left of her pension and retired to a bungalow in Duluth near her daughter and grandkids rather than trying to sell this group on the idea of using a new approach for aligning their services.
After more than forty years in human services, she had come to dread interagency meetings. It wasn’t the people – well, maybe sometimes it was the people – but mostly it was the circular conversations. There were times when she wanted to shout, “Why can’t we all just get along!” But then she remembered that was what Jack Nicholson, playing the president of the United States, said at the end of his speech to the Martian leader in the movie Mars Attacks, just before the Martian used a mechanical handshake to skewer Jack and declare victory over Earth.
When everyone was settled, Apollina looked out at the apprehensive faces around the table. Each person seemed to be wondering what new disaster she would inflict on them. So, instead of an agenda, she reached behind her and brought out a cake to share.
As she uncovered the still-warm pineapple upside down cake topped with golden rings of glistening fruit, each with a bright red cherry in the middle, Fred Armisen, the city of Kenyon’s police chief for the past 30 years, inhaled deeply and said, “If you are trying to bribe me with that cake, Apollina, you are succeeding. I don’t care what you’re up to this time, just give me a piece and show me where to sign.”
Apollina began cutting pieces of cake and passing them around the table. When everyone had some, she said, “Fred, this is not just a cake. It is also a diagram for our new system of care.”
“Mmph,” Fred said as he put the last forkful of cake in his mouth, then slid his plate toward Apollina. “That works for me as long as I can have just a bit more.”
Apollina knew less than a third of the group from her earlier days in Kenyon. From the apprehensive expressions on the new faces around the table, she knew she only had a couple of minutes to engage them.
“So, how many of you have made a cake like this?”
A few people raised their hands. Apollina nodded toward Augustus Waters, a young psychologist who had recently become the director of the community mental health center. She asked him, “What’s the secret to making a good pineapple upside down cake?”
“It’s not so much a secret, as just thinking about the cake from the bottom up,” he answered. “You mix your glaze and put it in the pan, then you set in the pineapple rings and cherries, and finally you pour the batter on top. You want to cut your pineapple slices thick enough to hold together during the baking, and your batter needs to be just the right consistency so that the crumb is light but firm.” He took a bite and then added, “I have to say that if this was a baking competition, you’d get a blue ribbon. But I’m not sure how a cake is going to help us straighten out the service systems in this county.”
Apollina smiled. “Good point, Gus. Even though I do believe that a good piece of cake can cure a variety of ills, in this case, the cake represents a new approach that I hope can bring some energy and direction to the work that we’re all trying to do.”
“Oh, it’s a metaphor,” said Hazel Lancaster, the lead public health nurse. “In that case can I have another piece of metaphor?”
With that, Apollina felt the ice was broken sufficiently for her to dive into her proposal.
Systems of Care Are Good Things, Except…
“Raise your fork if you are tired of building systems of care here in Kenyon County,” Apollina said, and saw raised forks and suspicious looks. “And yet how many of you wish we had a better way of working together when people have complex needs?”
More forks were raised, and the expressions changed to a mix between curiosity and incipient boredom.
“Okay, so what are the problems with the systems of care we’ve had over the years, including the one I helped put together in the nineties?”
Slowly, the answers came out:
Apollina listened carefully as each person shared their concerns. Then she asked, “So why do you keep trying?”
Kerry Pope, who Apollina had brought in to resolve issues in the child welfare division, said, “It’s simple. Because when we’ve worked together we’ve helped kids and families have better lives. That would never have happened if we were doing things on our own. What we’ve done may not be perfect, but it’s better than not even trying.”
“So, I think you are saying that systems of care are good things, except when they’re not. Maybe that means we need to build our next one differently,” Apollina said. Then she pointed to the layers in the one piece of cake remaining in the pan. “I wonder what would happen if, like we do with this cake, we started with the pineapples and cherries rather than the batter.”
Shifting to a People First Design
“Instead of creating a special but limited space where a group of our service agencies can work together, and then selecting the folks who can be helped in that space,” Apollina said, “we might begin by looking at how needs are distributed in our community and focus on improving all of our agencies’ abilities to respond more flexibly and naturally to complex and changing individual, family and community needs.”
Here’s what Apollina was getting at:
When health and human services planners agree that specific needs in specific communities are their focus of concern and that their task is to begin by understanding the people with those concerns, collaboration becomes people-driven. This means leaders and planners should work to understand people’s experiences of their needs, how the needs are changing over time, what drives the emergence of the needs, where the people with these needs are, how their situations vary, how they are doing currently and what they feel would help them do better. In 1970, one author put it this way in the context of responding to the needs of people with mental illnesses:
“At times like these, researchers are, or should be, thrown back to the first principles of description and classification, trying to see what the mentally ill are experiencing in the world and how they move about and what factors are associated with changes in status (clinical, economic, residential, etc.). Researchers should begin by studying lives: how they change, what remains constant, and most important, how the persons involved (especially the mentally ill person) shape the outcomes of interest. If we do not return to these first principles of social and clinical science, we face the unflattering possibility of distorting both the scientific endeavor and the policy-making process.”1
Ten years later, Jerry Elder and Phyllis Magrab offered a similar observation in their ground- breaking book, Coordinating Services to Handicapped Children: A Handbook for Interagency Collaboration. In the opening chapter, they point out that because the situations they studied “varied so much from community to community, along with the environment in those communities … [t]here is no set prescription or model that can be given or followed in a step-by-step fashion and applied to every community. Each community has its own unique characteristics, needs, political and geographic boundaries, and problems, and its own members are best prepared to address these issues and develop efficient, collaborative service delivery.” 2
This is people-first, or population-based health planning. There are many definitions of a population-based approach. Here’s one example:
“A population-based approach addresses the health care needs of a defined population of patients instead of providing just-in-time illness care to individuals. Population-based health care ensures design and delivery of evidence-based interventions that address the full continuum of care while monitoring performance results and encouraging changes in practice patterns to optimize patient outcomes.”3
When leaders start from a people-first perspective, they expand their organizations’ capacities to flexibly respond to emerging situations, such as teen suicides, frail elderly people with multiple and complex diagnoses and treatment regimens, children in foster homes, or those exposed to lead paint, or families where the parents have told their pediatrician that their children have behaviors that they cannot manage. This approach can also be applied when people in certain geographic locations are experiencing difficulties caused by the impact of local determinates of health, such as compromised and inadequate water supplies, excess heat, lack of fresh food, or the collapse of the local economy.4
The Collaboration Trap
In the following decades, the system of care movement expanded until most counties and states in America had some kind of collaborative interagency operation. However, research on the outcomes produced by these arrangements showed mixed results.
For example, eighteen years after Magrab and Elder’s book, Charles Glisson and Anthony Hemmelgarn published the results of a longitudinal study to assess the effect that increasing inter organizational services coordination had on child and family outcomes.5 The abstract of that article summarized the results of their study in this way:
“Findings show that organizational climate (including low conflict, cooperation, role clarity, and personalization) is the primary predictor of positive service outcomes (the children’s improved psychosocial functioning) and a significant predictor of service quality. In contrast, inter-organizational coordination had a negative effect on service quality and no effect on outcomes.”6 (emphasis added)
A year later, Leonard Bickman and his associates published the results of a multi-year study of a large-scale system of care in Ohio that was done as a follow-up to an earlier evaluation of a care coordination system in a federal demonstration project at Fort Bragg. The Ohio study compared youth who were served through the system of care with another group who received services without care coordination. In addition, the authors were also able to track a third group who did not receive any services at all. The abstract of that article summarizes their findings in this way:
“While access to care, type of care and the amount of care were better in the system of care, there were no differences in clinical outcomes compared to care received outside the system. In addition, children who did not receive any services, regardless of experimental condition, improved at the same rate as treated children. Similar to the Fort Bragg results, the effects of systems of care are primarily limited to system-level outcomes but do not appear to affect individual outcomes such as functioning and symptomatology.”7 (emphasis added)
In 2016 Mick Cooper and his associates published a comprehensive review of the past twenty years of research on the impact of interagency collaboration. They initially examined over 4,000 articles on the topic but were only able to find 33 that were useful and reliable for purposes of comparison. The authors summarized the results of their review as follows:
“Outcomes were mixed, with some findings indicating that interagency collaboration was associated with greater service use and equity of service provision, but others suggesting negative outcomes on service use and quality.”8
One of the difficulties that tended to undermine many of the system of care efforts was initially identified by Glisson and Hemmelgarn. They found that:
“In areas where coordination increased, caseworkers relinquished responsibility across the board [for activities associated with delivering quality services] based on the incorrect but expedient assumption that they would be assumed by the service coordination teams.”9
This is the collaboration trap. Sometimes when communities try to get multiple systems to work together, the result is not many hands make light work, but instead, too many cooks spoil the broth as collaborative partners spend more time interacting with one another than they do with the people their agencies are supposed to be serving.
Because they found that interagency collaboration works sometimes and doesn’t work other times, Cooper’s group identified the factors that seemed to promote and inhibit effective collaboration:
“The factors most commonly identified as facilitating interagency collaboration were good interagency communication, joint trainings, good understandings across agencies, mutual valuing across agencies, senior management support, protocols on interagency collaboration and a named link person. The most commonly perceived barriers to interagency collaboration were inadequate resourcing, poor interagency communication, lack of valuing across agencies, differing perspectives, poor understandings across agencies and confidentiality issues.”10 (emphasis added)
While most states and counties find it difficult to put all of the positive elements in place at the same time while avoiding the negative ones, a review of the literature provides some suggestions for strategies that communities can use to improve the effectiveness of their collaborative efforts within the existing constraint
Better organizational climates. Effective individual agencies have line staff who are able to collaborate naturally with staff from other agencies when a particular client’s needs require it. This is the perspective that Glisson and his associates took. They developed a systematic approach to improving organizational climate and have demonstrated that those improvements do result in better outcomes.11 They found that a positive organizational climate produces many of the attributes that Cooper, et al., found to be necessary for effective cooperation. Even though people who work in supportive environments generally produce better results, efforts to establish positive environments for human services workers are often short-changed as leaders struggle to manage the pressures of workload, resources, and increasing expectations.
Better information systems. Another strategy for improving the effectiveness of direct services is to incorporate tools that provide real-time feedback to practitioners so that they can see what’s working and what needs improvement. One system for implementing this approach was developed by Leonard Bickman. He and his associates have helped agencies create and implement management information feedback systems (such as dashboards) so that clinicians and managers can use continuous quality improvement techniques to gradually advance the outcomes that their systems are producing.12 The challenge with this approach is that even though many sites are buried under documentation requirements, they still lack fluid, flexible and well-designed information systems. This presents a classic ‘missing the forest because of the trees’ dilemma. As documentation increases, the ability to use data for effective decision- making gets buried under the weight of the forms that have to be filled out.
Blended funding. A third strategy is to link coordinated care with service funding through blended funding and the development of a carve-in or carve-out care management organization for people with complex needs, such as families with children who have severe emotional disorders. Wraparound Milwaukee was one successful pioneer using this approach.13 The challenge with this option is getting all of the stakeholders in the systems to agree to blend funds and to accept the autonomy and power of the care management organization to make critical decisions about service access, including the use of residential treatment. These arrangements can be difficult to compose in a way that is big enough to matter initially. Many sites may substitute a blended pool of flexible funds that are used around the margins of the service system while leaving out the larger funding decisions such as residential care. Over time this makes the original effort irrelevant to the big issues of each system. If leaders in a community don’t have the political will to “go bold” with their first blended pool, it is difficult to maintain as budget pressures increase and each new wave of leaders have a different idea about what the community’s priorities are and how they should be addressed.
Health Homes. A fourth approach takes advantage of the flexibility provided under the Affordable Care Act by establishing specialized health homes for children with severe emotional disorders. In a thoughtful and well-researched policy paper, David de Voursney and Larke Huang from SAMHSA have described the necessary elements of a health home that would meet the needs of a child or youth with a severe emotional disorder. They summarize their recommendations in this way:
“We define a health home as a care arrangement that maintains a continuous relationship with a young person and their family, provides a set of services that are central to the health care needs of the child or youth and their family, serves as a central point for the coordination of behavioral and physical health services and other supportive services inside and outside of the health sector, provides or coordinates culturally and linguistically competent care, and takes responsibility for the broader health and wellbeing of the young person being served.”14
Some of the challenges with using a health home model as the basis for establishing a system of care include finding a way to bridge the gap between health care and life care, working out the time and timing issues so that health care professionals can be fully engaged in the integrated approach – as opposed to marginalizing health care until it is a commodity that only needs to be accessed as an add-on when needed, and structuring the model so it has the solid feel of a true and present physical entity rather than an ephemeral collection of processes.
Underlying Challenges of System-First Designs
Even though these strategies show promise, high quality implementation is often beyond the capacity of many community human service systems. But even in locales that have the political will, resources, talent pool and capacity to implement one or more of these options, their efforts may still be weakened by the limitations of top down, system-first designs.
Top down models start by focusing on the system partners who will be part of the collaborative, and then establish specific circumstances for eligibility and rules for service delivery. For example, many systems of care for children and families require multi-system involvement combined with a diagnosed mental disorder as a basis for enrollment. These systems may also have strict limits on the number of youth and families who can be served and require that all enrolled families have teams that meet the same minimum number of times and that include the same membership categories.15
While Cooper’s article indicates that some states and counties using system-first designs have been able to address issues of shared responsibility, provide purposeful collaboration, and help enrolled individuals and families by providing a single point of contact, individualized and integrated plans of care and efficient access to treatment and services, these arrangements still present several challenges:
First, requiring individuals or families to be labeled “multi-system” for them to enter a system of care can say more about the services in a community than it does about the people to whom the label is given.
Second, the labeling needed to enter the system of care can cause more distance between the helper and helpee and result in the people receiving services becoming objectified. Individuals may become known as “mentally-disordered, multi-system clients” rather than our neighbors or fellow citizens with complex needs.
Third, even in specialized interagency settings that seem to be working, the people referred to these settings usually continue their original system ties. If the people who are enrolled in the specialized system of care are still connected with, or have mandates under other categorical programs in the community, the issues of interagency competition identified by Glisson and Hemmelgarn may be exacerbated. Lines of authority, responsibility and communication can break down over time and turn into a contest between the collaborative group and the home system in which a family or individual is lodged. Some sites resolve this by reducing engagement through a hand-off process from the primary care provider when the specialized program steps in. While this can lessen friction during the period of engagement, it often makes reconnection with primary services difficult when the individual or family’s period of engagement with the specialized service ends.
Fourth, specialized and highly resourced services tend to have limited enrollment capacity, so that even if they have successful outcomes with the specific individuals and families that have been admitted to the program, they often aren’t able to serve many of the other people in the community who also have similar complex needs. This can result in a feeling of increasing cynicism by the line staff from the various home systems who see the specialized effort as irrelevant to the needs of many of the people that they serve.
Finally, it assumes that there is a coherent subgroup of people in a community who are involved in multiple systems, when in fact heterogeneity is the rule. Thus the children who a pediatrician sees that have needs than span traditional categorical systems are often different from the youths that a juvenile probation officer is working with, and the frail elderly person with multiple needs that a public health nurse visits may be different from other older patients being seen in oncology, diabetes or rheumatology clinics. This heterogeneity means that the social determinates of health underlying the complexity of each person or family’s needs will vary, as should the response being made to those determinates.
An alternative to a top-down approach to designing a system of care might be one that harkens back to Elder and Magrab’s emphasis on the importance of locality and flexibility.
Creating Responsive Healing Spaces
Because the people living in communities have many different kinds of needs and many different ways of seeking and benefiting from assistance, and because those needs are changing all the time, for communities to be vibrant and healthy they need a wide variety of flexible and responsive healing spaces. For these spaces to serve the community effectively they should also be sufficiently inter-connected so that each person or family with complex needs can obtain the combination of assistance that is right for them.
This means that good healing spaces should provide: geographic proximity, so that people can get to the space quickly; resource deliverability, so that once in the healing space, people can quickly receive the help they need; and interoperability, so that helpers from multiple spaces can easily mesh efforts when needed.
Healing spaces should also be responsive, respectful and most importantly anchored to the cultures, identities and lives of the citizens who will be entering into them and have the capacity to adapt the assistance provided to fit with the characteristics of the individuals and families seeking help.
Not only do healthy communities need multiple and diverse healing spaces, the nature and structure of those spaces, the rituals for entering and engaging healing within them, and the ways the operation and upkeep of these spaces are sponsored and supported must also be able to change and adjust over time to match the people they are welcoming and the needs those people bring with them.
Healing spaces are not clinics or addresses, but instead should reflect a mutual, cross system commitment to creating and maintaining pathways to assistance so that people with complex needs are able to find the right amount of response to produce relief in the shortest amount of time. These spaces should be thought of as people, agencies and other community resources who together make an intentional commitment to follow certain practice patterns designed to produce a desired result. The point is not to enmesh everyone in the same bureaucracy but to find a way for them to all operate on the same or at least compatible wavelengths. That way unique acts of partnership can emerge as needed in ways that fit the equally unique situations of the people who are being helped.
Balancing Structure and Soul
Attempting to increase flexibility in a system of care creates a dilemma. On the one hand communities need large infrastructures to gather resources and distribute them equitably across multiple locations, which creates pressure for uniformity in practice, accountability, and resource access. But on the other hand, the push for uniformity and accountability makes it difficult to match the help offered through these resources with ongoing changes in the nature and distribution of complex needs in the community.
One size fits all can end up meaning that no one has a resource that truly fits them.
Balancing top-down prescription with bottom-up promotion so that evolving systems of care can avoid the collaboration trap and nurture the emergence of approachable healing spaces in every locality requires a strategy that can manage both large-scale resource distribution and accountability with indigenous responsiveness – a strategy that can balance structure and soul.
One way to create this balance is to start by reimagining the mental model of how systems of care are designed. This involves shifting from hierarchical system designs that mandate care to a new perspective that focuses on building networks to organize care. This change underlies many of the current developments in technology from smart cars and energy grids to finding places to stay and ways to get from one place to another.
Nesting People-First Design in Networks of Care
People-first design means listening to the concerns of individuals and families in a community and to their vision for what would be better. But their message can be lost in the long transition from local, community-anchored activism to state level implementation.16 To overcome this dilemma, system implementers must devise protocols to insure that local determinates of health and well-being are quickly and accurately identified and addressed, without strangling these efforts by excessive limits on who can be served, who can provide those services, and how those services can be delivered.
Shortening the time between need identification and service response and increasing the response bandwidth so that new and different needs can be addressed swiftly before they overwhelm a community presents a big challenge.
To respond to this challenge, communities need a platform for their system of care designs that:
Gathers, and aggregates and updates concrete data about the nature and extent of felt need in the community:
Alerts both those with the needs and those who are available to respond to those needs about the situation;
Cross references data about needs with potential services, supports or other forms of assistance that might be useful in the response;
Provides a forum for assembling a collaborative response to complex needs; and,
Generates connections for accessing the formal and informal resources needed to implement the responses.
Traditionally, both public and private organizations have used top-down models like enterprise architecture to support their collaborative infrastructures. 17 But emerging companies like AirBnB and Lyft use a different, bottom-up approach to generate their platforms. They use networking, virtual infrastructure and maximized customer choice to manage their operations. Like them, reimagined approaches to improving the integration and impact of human services should focus on growing emergent networks of care.
So that a network of care can quickly collect, analyze and respond to a community’s needs, its operational platform should be able to incorporate all of the key elements of a community’s service and helping opportunities in a holistic representation that captures both the evolving needs of the people and families in the community and the interrelationships that exist among the formal and informal healing spaces that currently exist to meet those needs.
Perhaps the best way for a community to improve its ability to get the right help to the right people at the right time and in the right way is to take advantage of advances in information technology by building multi-modal, multi-nodal, inter-connected, and responsive networks for identifying, generating, distributing and coordinating its resources for help and healing.
Each of these elements can help strengthen the flexibility and effectiveness of a system of care:
Multi-modal: The representation of the community’s healing and helping spaces in the platform should mirror the different types of helping activities in the community including all of the formal and informal types of assistance that are present or are hoped to be present in a community, from housing and transportation, to wellness program, to primary health care, to time banks, to specialized care. Somewhat analogously, AirBnB and Lyft maintain constantly updated maps of the rental and transportation options in a given location that maximizes choice for someone looking for a place to stay or a way of getting around.
Multi-nodal: Modes describe the various ways help happens in a network of care. Nodes show the points where the various pathways of helping intersect. The platform for a network of care should capture these connection points as they emerge or become identified, including the best ways for a person or family to link with specific individuals, organizations and other resources who provide or support healing and helping efforts in a community. As with AirBnB and Lyft, a person seeking help should be able to quickly sort through helping options in the same way they would decide whether they wanted to rent a condo, a spare bedroom or a whole house and elect whether to ride there in an SUV or a hybrid.
Inter-connected: The platform for a network of care should be able to identify the nature of the formal and informal relationships between the modes and nodes of the network, reflecting where good help and connections exist and where better ones are needed, how they operate, and how they are changing over time. Each of the various spaces should be able to produce a reliable pathway to healing without making that pathway more important than the person entering the space. To stretch the AirBnB and Lyft analogy a bit further, the network should be able to identify the current distribution of service options across neighborhoods to guide the development of new options, and describe differences and similarities in access and exit rituals for a given type of option to improve the usability of each resource. (For example, does the host leave the key for the apartment in a box, or do guests have to meet with the host before checking in? Do guests strip the beds or put the towels in the washing machine before leaving?).
Responsive: The platform for the network cannot be a static representation but instead should have the capacity to continually update, grow and incorporate additions and changes in modes, nodes and connections as well as input from the community, consumers and providers about what is needed, what is working and what needs to work better. AirBnB and Lyft can easily add new hosts and drivers but also have systems for rating the quality of the services that existing hosts and drivers provide and respond to suggestions for new types of services. Both platforms grew organically from very small beginnings to include broad geographic areas and a wide range of services.18
If this seems to be an impossible level of infrastructure to imagine, let alone build, consider how easy it now is to identify a place to stay in almost any community in the world using programs like AirBnB that will tell you whose place it is, what it looks like, whether it matches with the type of home or room you are looking for, how other guests have evaluated the place, what the hosts are like, and even tells the hosts something about the people who are inquiring about a place to stay.
A well-connected network of care would be a platform where multiple helping and healing opportunities are linked and customized according to the needs and wishes of the people and families that need help. In this way, it would let everyone in a community find the right help at the right time as efficiently as a person can find a good place to stay for their next vacation.
Starting with the Basics
“We’re talking about human lives and not just vacation stays,” said Chris Cooper, the grizzled, head of Kenyon’s family advocacy organization, after Apollina had shared her ideas for re- imagining their system of care as a bottom-up network.
“Absolutely, Chris,” Apollina said. “I don’t want to rush into anything. We need to reconnect with the community at the same time we are working to re-invigorate our agencies after they’ve gone through so many disruptions. But how about if we start by re-asserting the basic values we want to see expressed as we put things back together?”
With that Apollina’s team, who began to call themselves the Pineapple Express, developed a work plan for developing and implementing a set of shared values to inform the way their new network of care would be constructed. For some it felt like the work over the following months was duplicating efforts that had taken place in the past. But for most the inclusion of population-based planning and the emphasis on creating a model that could flex its targets and response protocols based on changing needs in the community was exciting.
Using community generated values statements as a frame for their system operations required more than simply adopting a list. It meant that each manager had to spend time with both their clients and their staff listening to their perceptions of what was working and what could work better. They had to talk to people in the wider community to identify areas of need that the current system was not addressing effectively. They had to find an organization willing to host the new platform for gathering an accurate and responsive network of need expression and response resources in the county and the technical support for designing and assembling the interactive database.
The Pineapple Express Team agreed that when establishing a statement of shared values, less was more and that efforts should be made to assure that the language reflected a covenant between the helpers and helpees and other members of the community who were working toward the same goals.
In the end, they came up with ten principles to support consistency and alignment as modes, nodes and connections were added to their network of care, and its responsiveness was measured and improved.
Here’s what they proposed:
Coordination Counts: Our network of care helps individuals, families and our community deal with complex life challenges through well-coordinated action plans that build on strengths to meet the critical needs that are the driving forces underlying those challenges.
People Participation: Effective action plans must be developed with the active participation of the individual, family, or community members involved and be reflective of and responsive to their voices and choices.
One to One Responsiveness: Every individual, family and community situation is unique, and plans to help those involved deal with complex life challenges should be equally unique, with solutions, services, assistance and strategies that are well-aligned with the situation, culture and preferences of those individuals, families or community members, and take into account ways in which poverty, trauma, or other circumstances may have impacted them.
Learning Lessons from First Efforts: Our action plans are tools for learning as well as helping. Once we commit to help an individual, family or group of community members, we pay careful attention to what is working and what needs to work better and use that ongoing input to adjust the plan as needed until the individual, family, or community group has surmounted the obstacles for which they sought assistance.
Everyone Can Help: Based on the story of the individual, family, or group of community members, and with their permission we may invite additional people or organizations from our network who are likely to be useful in dealing with the obstacles that have been identified. These people or organizations may be sources of formal or informal assistance and support, both.
Form Follows Need: When individuals, families or organizations identify a situation that affects the well-being of large groups of people in our community, or the well-being of the community as a whole, the network of care may convene a collaborative action forum to devise a community-wide action plan that builds on the strengths and cultures of our community.
Welcome, Help, Learn, Improve: The basic process we follow in developing action plans for individuals, families or community members who present their concerns to the network of care is:
Welcoming. We begin by welcoming the individuals or families or groups who are presenting a concern, taking the time to hear their story, and from that story identifying their expressed and hidden strengths and/or those of the community surrounding them, inferring potential driving forces underlying the area of concern, and formulating a brief statement of how things would be if the concern were to be effectively addressed that will serve as the guiding mission and call to action for the effort.
Helping. We bring together additional people or organizations as needed to develop and implement a strength-based action plan to address one or more of the underlying driving forces affecting the people who come to us for help.
Learning. We monitor the implementation of the plan and make adjustments as necessary to improve its effectiveness with an ongoing commitment to do whatever it takes to finally resolve or manage the identified concern.
Improving. We develop a follow-up plan as needed to provide for ongoing support to the individual, family or group of community members, and/or to support the continuing efforts of the community to keep the identified concern in check when the individual, family or group of community members is near to accomplishing the mission that was formulated.
Open Access with Continuous & Participatory Review: The network of care will provide opportunities for interested individuals to become trained to facilitate strength-based action planning. Those who complete the training will be listed on the network as potential resources and can be chosen by individuals, families or community groups to coordinate a response to the concern that they are posting. As with all resources listed in the network of care, available action plan facilitators can be rated by those who use them. Facilitators can indicate the type of concerns they have helped individuals, families or community-groups address and note whether they are offering their services on a voluntary basis or if they charge a fee.
Everyone is an Investor: The network of care is a stand-alone non-profit entity. Its operations and resources are supported by joint contributions from organizations committed to improving the health and well-being of the community including health care organizations, insurance companies, school districts and the community’s human services agencies. It is hosted by a neutral organization with a sufficiently large information technology infrastructure to support the network’s platform. The network is curated by a community board with diverse representation and operated by staff hired by the board. Allocations from the network toward the implementation of action plans
is done according to guidelines developed by the board, with smaller allocations automatically approved and larger commitments requiring board approval.
Option Versus Substitution: The network of care supplements and supports the efforts of the community’s health care and human services agencies but does not replace them. Most help happens through the ongoing efforts of those other groups. The network is there to respond quickly and efficiently to emergent community issues and challenges, to provide a resource for individuals and families whose needs and concerns fall between the cracks in the current array of human services, straddle multiple services leaving primary responsibility unclear, or present such complex challenges that a coordinated effort is needed to develop and implement a creative solution to the situation.
It was a start, but Apollina and the Pineapple Express Team had to cook up a lot more cakes, pineapple and otherwise, before they felt like they had a viable recipe for the new design. One of the challenges was to help each service agency concentrate on establishing or re-establishing its own positive organizational culture but to do it in a way that supported spontaneous and flexible cooperation with a wide variety of other resources depending on the needs of a given individual or family.
“The difference,” as Fred put it when he met with the mayor to explain what was going on, “is that in the past we would spend a lot of time getting a select group of agencies to work together. It was like belonging to a club with a bunch of rules. We helped a quite a few kids and families, but we missed many others because we didn’t always have the people in our club that we needed, or important club members would drop out, or because we didn’t have room for all the people the club wanted to help. Now we sort of got rid of the membership hassles. If a doctor has a patient that could use some extra help, she taps into the network and pulls together the folks that are needed to deal with that patient’s specific situation. Same for one of my juvenile officers or a teacher or a social worker.
“So, there are no more rules?” The mayor said, looking skeptical.
“Well, we don’t so much have rules as guidelines,” Fred answered after a short pause. “You see, we’re all one cake, but in it there are many pineapples.”
“You realize that I have no idea what you’re talking about, don’t you Fred?”
“It’s a metaphor, Mayor. Just a metaphor.”
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1 Lewis, D.A. (1990). From programs to lives: A comment. American Journal of Community Psychology, Vol. 18, No. 6.
2 Elder, J.O. & Magrab, P.R. Coordinating Services to Handicapped Children: A Handbook for Interagency Collaboration. Baltimore: Paul Brookes, p. 3.
3 Rychnovshy, J. (2003). Population-based health care. Journal of Pediatric Health Care, v. 17, n.
3, pp. 154-156 at 154.
4 Cf. Block, R.W. (2015) Recognizing the importance of the social determinates of health. Pediatrics, v. 135, n. 2, pp. e526-527. “There is an urgent need to recognize the importance of toxic stress, childhood adversities, and other social factors as we provide pediatric care to children. What good is providing routine care exemplified perhaps by giving an immunization, if a child leaves the office to continue living in poverty, with food insecurity, maternal depression, lack of affordable child care, violence in the home, drug abuse, and other adversities?
5 Glisson, C. and Hemmelgarn, A. (1998) The effects of organizational climate and interorganizational coordination on the quality and outcomes of children’s service systems. Child Abuse and Neglect, v. 22, i. 5, pp. 401-421.
6 Ibid, p. 401.
7 Bickman, L., Noser, K., and Sommerfelt, W.T. (1999) Long term effects of a system of care on children and adolescents. The Journal of Behavioral Health Services and Research, v. 26, n. 2, pp 185 – 202, abstract quote at 185.
8 Cooper, M., Evans, Y., &Pybis, J. (2016) Interagency collaboration in children and young people’s mental health: a systematic review of outcomes, facilitating factors and inhibiting factors. Child: Care, Health and Development, v. 42, n. 3, pp. 325-342, at 325.
9 Glisson and Hemmelgarn, op. cit., p. 417.
10 Cooper at 325.
11 See, for example, Glisson, C. and Shoenwald, S.K. (2005) The ARC organizational and community intervention strategy for implementing evidence-based children’s mental health treatments. Mental Health Services Research, v.7, pp. 243-259; Glisson, C. and Green, P. (2011) Organizational climate, services and outcomes in child welfare systems. Child Abuse and Neglect, v.35, i. 8, pp. 582-591; and Glisson, C. & Williams, N.J. et al. (2016) Increasing clinicians’ EBT exploration and preparation behavior in youth mental health services by changing organization culture with ARC. Behaviour Research and Therapy, v.76 pp. 40-16.
12 See, for example, Bickman, L. (2008) A measurement feedback system (MFS) is necessary to improve mental health outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, v. 47, n. 10., pp. 1114-1119; and Bickman, L. (2012) Why can’t mental health services be more like modern baseball? Administration in Policy and Mental Health Services Research, v. 39, n. 1, pp. 1-2.
13 Kamradt, B. (2000) Wraparound Milwaukee: Aiding youth with mental health needs. Juvenile Justice, v. 7, n. 1, pp. 14-23.
14 De Voursney, D. & Huang, L.N. (2016). Meeting the mental health needs of children and youth through integrated care: A systems and policy perspective. Psychological Services, v. 13, n. 1, 77-91, at page 79.
15 The impact of strict limitations on access to specialized services was discussed in detail in Miles, P. & Franz, J. Apollina Smith and the Amazing Exploding Triangle: A Cautionary Tale on the Hazards of Large Scale Integration of Human Services. (1995) Available on line at: http://paperboat.com/images/stories/ArticleArchive/Apollina%20&%20the%20Triangle.pdf. The current article is an expansion on the ideas presented in the Amazing Exploding Triangle article in light of 21 additional years of experiences with systems of care.
16 The challenge of the delayed response to perceived community need was discussed in The March of the Army Ants, (1994) by Pat Miles, Neil Brown and John Franz. The article can be found online at http://paperboat.com/images/stories/ArticleArchive/March%20of%20the%20Army%20Ants.pdf
17 An overview of enterprise architecture can be found online at http://feapo.org/wp-content/uploads/2013/11/Common-Perspectives-on-Enterprise-Architecture-v15.pdf
18 AirBnB started with three air mattresses on the floor of the San Francisco apartment of two men who rented them out as a way to help pay their overdue rent.