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![Page 1: Laurel K. Leslie, MD, MPH Associate Professor of Medicine and Pediatrics Tufts Clinical and Translational Science Institute Tufts University Boston, MA.](https://reader035.fdocuments.net/reader035/viewer/2022062304/56649e7b5503460f94b7c1b0/html5/thumbnails/1.jpg)
Great Starts: Leading Change in Your State
Laurel K. Leslie, MD, MPHAssociate Professor of Medicine and PediatricsTufts Clinical and Translational Science InstituteTufts UniversityBoston, MA
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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
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Change in Many Organizations
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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
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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
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Create and increase urgencyCreate a teamGet the vision and strategy right
Create a climate for change
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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
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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)
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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
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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)
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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
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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
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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
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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
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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
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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
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Communicate the vision for buy-inEnable action
Engage and enable change
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Step 4. Communicate the Vision
Simplicity Metaphor, analogy, example, story,
picture Multiple forums Repetition Two-way communication
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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
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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
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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
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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
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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!
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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
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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
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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
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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
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"Together we can reach the heights of excellence and perform the extraordinary."
Concluding Remarks