Great Starts: Leading Change in Your State

Laurel K. Leslie, MD, MPHAssociate Professor of Medicine and PediatricsTufts Clinical and Translational Science InstituteTufts UniversityBoston, MA

Promoting Change

Opportunity Improve mental

health well-being of children in foster care

Danger Change is

unpredictable, costly Requires people and

organizations to change

Competes with other initiatives

Change in Many Organizations

Leading Change By John P. Kotter & used by the Children’s Bureau Training and Technical Assistance Network

Create a climate for changeCreate and increase urgencyCreate a teamGet the vision and strategy right

Engage and enable for changeCommunicate the vision for buy-inEnable action

Implement and sustain changeCreate short-term winsDon’t let up: build on gains and produce more changeMake it stick: Anchor new approaches in the culture

Tufts Research Team

2 national studies: 2009-2010 (Charles H. Hood Foundation)▪ Examine state policies and best practices and

disseminate to child welfare agencies

2011-2012 (William T. Grant Foundation)▪ Identify types of information states using to

develop plans

▪ Investigate monitoring approaches

Create and increase urgencyCreate a teamGet the vision and strategy right

Create a climate for change

Step 1. Create and Increase Urgency

Identify medication use as a systems problem “This issue has never been looked at on an

organized basis. It has always been left up to the individual case workers.” -Child Welfare

Gather data on medication use “The data brought us together.”

-Child Welfare

Build on multiple “messages” “We’re hearing it from the line and we’re

certainly hearing it from the feds and so that’s certainly making us take a little bit of a closer look more so than we ever have before.” -Child Welfare

What Drives Urgency Around this Issue?

Child welfare Line workers’ concerns Advisory/consumer board concerns Leader or champion

Other child-serving agencies Mental health reform for children served by public systems Medicaid: cost, safety and quality initiatives Pediatrician/Psychiatrist best practice efforts

External factors High profile media cases Legislative or accountability commission attention SSI investigations Federal attention (e.g., GAO, ACYF)

Step 2. Create a Team (1)

Include all key stakeholders Requires content expertise beyond any 1

agency. This “can’t be done alone.”-Child Welfare

“Include all of the stakeholders in the policy development - get them to voice their concerns and be a part of the process. Will likely lead to greater buy-in with the policy.” –Child Welfare

“It wasn’t until we made it a larger conversation that we made progress. Don’t develop policy-practice in isolation.” -Child Welfare

Who are You Partnering With?

Common partners: Medicaid (82%) Mental health (73%)/MCO (18%) Juvenile justice (23%) Academics (64%)▪ Medicine/Psychiatry▪ Pharmacy

Judiciary (23%) Consumers (e.g., youth and caregivers)

Other Partners

Indian Health Services Contract agencies: residential, foster

care, adoption Health department Professional organizations (AAP,

AACAP) Funders (Casey, local foundations) Neighboring state agencies or

academic institutions Other states in a collaborative

Linking Across Systems

“There’s not a tight recognition that your medication management needs to be really tight with your ongoing therapies and your social support system. They’re sort of too delinked in my opinion and to the extent that we can bring them back together, I think, is the important piece.” -Medicaid

“The shortage that we have with child psychiatrists in this state, especially in . . . some of our rural areas. These kids are seen by primary care physicians, so what can we do to our sister agencies to help them understand mental health issues because they are not psychiatrists? “ -Child Welfare

Step 2. Create a Team (2)

Find the people with the skills you need Agency Content (ex: pharmacy, IT) Power, expertise, credibility, leadership, and

management skills Role of “boundary spanners”; requires

multiple perspectives—not just data and requires concerted effort among and across agencies

Build on existing high functioning teams

Step 2. Create a Team (3)

Use them in the multiple way(s) Guiding coalition (core team ) Advisory boards/panels Project-based teams Advocates or supporters Criteria

Step 2. Create a Team (4)

Identify, acknowledge, and address differences across agencies Language/terminology Missions Eligbility criteria

Hold each other accountable Organizational Agreements , MOUs, or

Guiding Principles Public meetings

Step 4. Get the Vision and Strategy Right

Vision and strategy Articulate your vision▪ What is it? ▪ Appropriate mental health treatment : “ The right care at the

right time.”▪ Meds reduction: “Too much, too many, too young”

▪ Characteristics: Imaginable, desirable, feasible, focused, flexible, easily communicated, measurable

Develop your strategy

“We had a whole group. We came up with a vision. We came up with principles and guidelines of where we want to be. Then we came up with strategies and plans and actions. Then we moved forward in implementing quite a few of those.” -Child Welfare

Communicate the vision for buy-inEnable action

Engage and enable change

Step 4. Communicate the Vision

Simplicity Metaphor, analogy, example, story,

picture Multiple forums Repetition Two-way communication

Step 5. Enable Action (1)

Ask: What do you need

to implement your vision?

What resources are available that you can leverage for change?

What new resources are needed and where can you get them?

Personnel-new hires, training▪ Leadership, IT, staff

level Technology/data

systems Organizational

structure Procedures and

policies Evaluation Funding

Leadership Training

“I along with some of the other managers have participated in some of the work that is being done by ACF in terms of the leadership academies. I think that –so that is where some of it has come from. I think as we have looked at change and change in our agency, we are getting some –just talking more about and getting technical assistance as well on how we are going to move through the change process.” -Child Welfare

Facilitative Structures

Organizational structure: “And what's interesting is that we all sit in

the same building. We have a central office where those directors sit together in the same little pod. And then we are together within the same building and we aren't siloed by floor. Does that make sense? Like public health sits next to us. Medicaid is on the same floor. So we don't silo ourselves as far as like behavioral health has their building, we have ours.” -Child Welfare

Funding

Funding “What we do is we combined monies across all the

different –there are always different funding sources. We had like fourteen or fifteen different funding streams serving basically the same kids in the community, just depending on which door they walked through. . . So we then allocated those[blended] funds to communities . . .who then get together to plan the services for the individuals.“ -Child Welfare

Grants-contracts and/or research grants; may require partnership with academics▪ Federal (NIH, SAMSHA, CMS)▪ State▪ Learning collaboratives▪ Health department QI projects

Step 5. Enable Action (2)

Partner with other states Expanded network for ideas, policies,

and procedures Expertise and capacity you lack

The QI motto: Share often and borrow shamelessly!

Create short-term winsDon’t let up: build on gains and produce more changeMake it stick: Anchor new approaches in the culture

Implement and sustain change

Step 6. Create Short-Term Wins

Provide evidence that work is worth it How will we evaluate our efforts?

Help fine-tune vision and strategies (QI processes)

Keep key stakeholders engaged Reward change agents with a pat on

back Keep leadership, champions, staff on

board

Examples of Wins

Examples of specific projects Agreement on core outcomes▪ Too much, too many, too young

Youth empowerment Transition-age youth Cross-agency kids (CW, MH, Ed) Shared databases

Steps 7 & 8. Don’t Let Up and Make It Stick

New approaches sink in only after it’s clear they work Need to have mechanism(s) for

identifying change as a win and disseminating the wins

Make successive changes that are compatible with vision and with culture you are seeking to build

May involve turnover

"Together we can reach the heights of excellence and perform the extraordinary."

Concluding Remarks