System lessons

History

Vermont in the 1980s was not a good time or place to be a child with mental health issues. There was no organised system to address child mental health needs in homes and community settings. The agencies charged with their care – mental health services, education, juvenile justice, substance abuse, child welfare and so on – operated as discrete and insular entities, resulting in a patchwork of care featuring overlaps and gaps.

There were long-standing contracts with status quo providers and because funds were tied up in those contracts, service provision in the community was poor. There was also an unwillingness among service providers to do things differently, and financial disincentives to change. And there wasn’t much engagement with families, with some providers seeing parents as one of the reasons for their children’s mental health issues.

In his book A View from the Balcony: Leadership Challenges in Systems of Care, Gary De Carolis, former chief of the federal Children’s Mental Health Branch, SAMHSA, sets out how this unfortunate state of affairs was turned around by promoting more effective inter-agency working and adopting a new approach to stakeholder engagement, leadership, resources, communication, service design and policy.

Developing new care principles

The first step was to devise and implement a new system of care principles that every agency could get behind. These were grouped under six headings:

Families as partners

• Involving families in designing, implementing and evaluating systems and creating policy
• Inviting families to sit at the table at all meetings, not just boards – an approach summarised as ‘nothing about us without us’
• Providing families with training and tools to be able to operate as equals in decision-making.

Interagency collaboration

• Facilitating all agencies working together on behalf of the population – for example by creating teams, committees, governance structures
• Individualizing plans of care – to address the whole person
• Ensuring all agencies applied their resources for the person and their family
• Resolving agencies’ cross-cutting issues around policy, programme gaps, and funding
• Encouraging agencies to collaborate to set up system-wide management information systems, training programmes, blended funding, unified communication
• Viewing patients as a community-wide responsibility (agencies are not pushing off costs/ responsibility on each other)

Individualised care

• Focusing plans of care on individuals’ strengths
• Ensuring interventions were evidence-based and addressed the whole family, including cultural considerations
• Blending financial resources to support the plan from all relevant public and private providers
• Ensuring plans supported people in their home communities

Cultural competence

• Taking cultural backgrounds into account, including religious, racial, ethnic needs
• Providing cultural competence training for all staff
• Ensuring staff were culturally diverse and reflect the community

Community-based care

• Building care plans on natural support of family, friends, neighbours, and institutions (places of worship, social and community groups, schools, etc.)
• Avoiding moving patients, as it caused additional stress

Accountability

• Measuring outcome data at system and individual level, tracking all the key demographic factors, referral sources, primary and secondary problems at intake, previous service history, family history, school/ work performance, current living arrangements, costs
• Guaranteeing confidentiality of patient data
• Proving (with data) to the taxpayer that investing in systems of care improves outcomes
• Ensuring there was a strong evaluation component of programmes.

Establishing consensus

New approaches were developed for engaging with stakeholders, managing communication, building dispersed system leadership skills, re-allocating resources, re-designing services, and influencing policy.

And the new care principles were adopted by system partners as a shared vision. A steering committee was set up, featuring families, providers, political leaders, state and local administrators across the child service systems of education, mental health, juvenile justice, health, substance abuse, child welfare, politicians.

The committee held meetings in communities across the state, taking two years to cover the whole state. At these meetings, local people were invited to share stories and demonstrate what was needed to create an ideal system. Families were invited to express their needs and comment on the strengths and weaknesses of existing services and the committee could educate communities about the goals. And the public were invited to observe for the rest of the meeting, so all items were discussed openly and transparently, including blended funding mechanisms. The committee also met with families individually.

The partners carried out a needs assessment that involved families and submitted the top two needs to commissioners of child welfare, education, etc., who put those requests in their plans. In the second year, they moved to the next two top needs. The assessment provided an evidence base for selecting initiatives and enabled an incremental continuous improvement approach.

They also spread the available money state-wide so each community could serve a few people and build impact evidence. They balanced infrastructure development and system reform needs with programme implementation work. And they provided resources for voluntary and community groups and social enterprises.

Communication measures included the creation of an interagency newsletter for the professional and parent community to share information and role-model new skills. Also, the public meetings were used to generate publicity at each place across the state, including local TV and radio interviews, to build a bank of positive stories backed up by hard outcomes data to counter the occasional negative story, and to capture the hearts and minds of residents and local politicians.

Teams, set up locally, met regularly to coordinate service plans for those whose needs could not be met by one agency, to design new services, and to escalate unresolved issues to the state interagency team. And interagency processes and structures were established.

The state-wide team took time to design services to understand how a new service protects other services and the overall system. They learned that creating interagency teams required defining specific goals and a path to achieving them. And information was shared across teams – as long as parents agreed.

The extended team worked with local government to develop effective policies to support system stability and sustainability, in the face of economic and political challenges.

Outcomes

The impact of the programme was widespread and long-lasting, with interagency collaboration codified in law in 1988 in Vermont. The programme grew from under $5m in 1992 to over $100m in 2005. And the system of care principles were adopted in other areas, including the juvenile justice system.

Questions for integrated care boards and system partners

• To what extent have you been able to accelerate your development by drawing on best practices from other countries and sectors?
• Could the System of Care Principles, developed in Vermont, helpful in defining an agreed vision for your integrated care system?
• How are you changing the way you engage with stakeholders and manage communication?
• To what extent are you building dispersed system leadership skills?
• To what extent are you applying systems thinking to re-allocate resources, redesign servies and influence policy?

Want to discuss further?

Over the past two years, GGI has supported almost half of the 42 integrated care systems. If you would like to hear more about emerging approaches across ICSs or options for GGI support, including taster sessions, please do not hesitate to contact Fenella McVey or Aidan Rave.