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Creating community systems of care: Can a D-I-Y approach work?
At our home, we’re all into into “d-i-y.” Sam watches the home renovation shows and Pete likes car repair shows. And, I’ll admit that one of my great joys in life is fixing things.
Interest in “do it yourself” programs has taken off, I suppose, as a result of the economic climate—a climate in which fewer people have the money to hire others to solve problems and therefore are compelled to become do-it-yourselfers. These popular shows demonstrate that fortune favors the bold—those willing to take on big risks with small budgets, quietly trading sweat equity with friends in the hope of big returns.
Tuesday, I attended a conference in Cleveland, sponsored by six prominent state and county boards and institutions involved with developmental disabilities, mental health, substance abuse treatment, courts, law enforcement, and criminal justice and probation. The conference attracted some 200 professionals—directors, attorneys, judges, police, social workers, nurses, counselors, and more—for a discussion about “Maximizing system-wide efficiency and treatment effectiveness for persons with developmental disabilities and mental illness through collaborative, coordinated and data-driven innovations.”
In this and any business, of course, conferences about “maximizing system anything” are pretty common. Seasoned observers might argue that any such titles beg two questions: “How? (what breakthrough did you uncover?)” and “Who funded it?” Tuesday’s audience brought in the same questions, but were surprised, I believe, by the answers they heard in a three-hour forum led by Leon Evans, CEO of the Center for Health Care Services in San Antonio, Bexar County, Texas and his colleague, Gilbert Gonzales. Evans and Gonzales explained that their local effort to achieve two simple goals—preventing inappropriate incarcerations and unecessary ER visits for individuals with behavioral health and DD problems—did not evolve into a comprehensive and nationally recognized system of care because it uncovered breakthrough knowledge or received a big-dollar startup grant. (Texas, Evans noted, ranks 53rd in behavioral health funding per capita—behind even Guam and Puerto Rico)
Instead, it started with almost nothing and worked because they, along with city and county leaders and organizations began to work together, ultimately creating Evans calls “community collaboratives.” The road to building these collaboratives—risk-sharing partnerships among interested (and invested) community entities—was often bumpy and difficult. Early on, the most common response from would-be “partners” in proposed efforts was “Good idea, but not with my money or my people,” said Evans. Only after a couple of years of effort—and a lot of meetings, listening, discussion, experimentation, and data collection—did initial efforts yield any significant or reportable results.
In the absence of funding, the early partners shared what they had: problems, priorities, personnel, ideas, and effort. With progress came more problems and more challenges, but the trust, experience, and data gained enabled the local partners to reason more and more confidently with each other, and with new prospective partners, for greater resource sharing and deeper investment in the problems they learned about and faced together.
Example: One element of the collaborative, a roundtable of local hospital, medical, and law enforcement leaders, found that 200 intoxicated citizens were flowing from arrest through court to jail each month. While detention, booking, magistration, and jail were exceedingly costly and clearly inappropriate for these offenders, there was no effective interception/diversion alternative for police until the collaborative considered the merits of a local “crisis/sobering” facility. Once in place, the facility made a huge difference for all partners involved.
Example: A significant proportion of Bexar County’s jail population consisted of individuals with mental, substance use, or developmental disorders—people who, if connected to local resources and follow-up, could live and be treated in the community at a fraction of the cost of jail or prison. But local judges were reluctant to divert offenders to court-ordered treatment in lieu of incarceration because they—and local probation officers—didn’t have treatment planning expertise. When a collaborative partner offered professionals that could provide treatment plans and work with the judges and parole officers, it didn’t take long for officials to notice a huge impact on the local jail population.
Lesson: Once the costs of an existing problem become clear to collaborative partners—and through them, to the represented segments of the community—the resources to support obvious solutions are readily found.
Over time, the collaboration’s efforts—linking public and private resources, governmental departments and healthcare providers, businesses and community service organizations—were strong enough to win the confidence of Texas legislators who embraced Bexar County’s efforts as the basis for funding a new “community collaborative” approach to crisis care and jail diversion throughout the state. And the community collaborative went right on with its efforts, bringing in schools, hospitals, community services of all types. In time, the collaborative earned a huge local donation for another innovative approach: A community homeless campus that welcomes all, but links those committed to personal change with higher levels of treatment, education, and employment supports aimed at the goal of restoring their independence in the community.
Of course, what works in Bexar County, Texas won’t necessarily work in Cuyahoga County, Ohio, Evans warned the many professionals and officials in attendance. “What will work for you is what meets your needs, your priorities, and your local goals,” he said. Most important, he emphasized that solving problems need not begin with cash from legislators, but could instead start with collaborative local effort.
Which brings me to a final thought: Interested officials and sponsor agencies, led by Cuyahoga County DD director Terry Ryan, made a brave first step by considering the dramatic story of Bexar County’s system transformation as an example—and a challenge—to Cuyahoga and other counties throughout the state of Ohio. But in the likely absence of any new resources, can they “do it themselves”? Can they overcome the obstacles that stand in the way of effective collaborations to blend and braid their resources? Can they do so in a way that will better and more justly serve not only those who need their services, but taxpayers as well? Only time—and effort—will tell.
