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Systems Transformation for Underserved Populations – The Colorado Daylight Project

Systems transformation, which we explore further in our Resources for Igniting Systems-Wide Change Blog, can be applied to just about any type of population with a defined need. In this week’s blog, we’ll explore how one project is approaching systems transformation for a particularly underserved population: the deaf and hard of hearing in Colorado. This effort, called The Colorado Daylight Project (CDP), is a collaborative approach to systems transformation led by the Mental Health Center of Denver and the Colorado Commission for the Deaf and Hard of Hearing.

 

Getting the Right People in the Room

Good systems transformation efforts begin by taking the time to make sure they have all the right stakeholders involved. Sometimes these stakeholders are obvious – for example, representatives of the various agencies providing services – but it is important to look beyond the ‘usual suspects.’

In 2008, providers who wanted to advance access to behavioral health services to Coloradans who are deaf and hard of hearing were brought together from mental health, substance abuse, adult and aging services, deaf and hard of hearing, education, and consumer and family advocacy organizations. By bringing together publicly funded behavioral healthcare providers from throughout Colorado, the Colorado Daylight Project was able to leverage a wide range of expertise in working with deaf and hard of hearing persons and create opportunities for cross-training and sharing resources. But it also went further, bringing in a variety of advocacy organizations, some with a focus on deaf consumers, others focused on hard of hearing consumers, and yet others who advocated for behavioral health services but had not historically advocated for or made their efforts accessible to deaf and hard of hearing consumers.

 

Laying the Foundation

Another important step in making sure your systems transformation effort is successful is the thoughtful, informed creation of a clear plan of action.

Once convened, The Daylight Project’s key stakeholders formed a Task Force that was able to develop an Action Plan where all the goals, strategies, and actions are built on three essential components: Governance Structure, Standards, and Consumer and Family Leadership. The Task Force used a variety of strategies to create the plan, including a statewide needs assessment survey, a consumer survey, research into the practices underway in other states, and facilitated planning sessions.

 

Implementation

Having made their plans, the Daylight Project then moved on to implementation by breaking the action plan down into manageable pieces and forming seven overlapping teams to move forward on individual elements, with each team reporting regularly and receiving advice and feedback from the full group of stakeholders (called the Implementation Team). The teams worked for a two year period to develop, among many other things, the standards of care outlined in the Action Plan, guidance for the standards of care, and multiple trainings. Similar to the planning process, research was used to support these activities, including best practices research to inform the standards; evaluation to provide ongoing feedback to the initiative, including to improve the trainings; and needs assessment to guide the work with provider agencies.

The Core Team

A “Core Team” composed of ½ deaf and hard of hearing leaders and ½ consultants and staff to the project were responsible for carefully coordinating, connecting, and overseeing the many teams focused on different topics.

The Consumer/Family Team

One of the teams played a critical role in guiding the work of the Daylight Project – the Consumer and Family Advocacy work group. They developed culturally competent advocacy trainings accessible to deaf and hard of hearing individuals, families, and natural supports in the community. Their focus was building a cadre of advocates who could not only inform the work of the Daylight Project, but advocate for systems change in the behavioral health system more widely.

The Provider Team

Another team was the Learning Collaborative, a group of eight provider agencies who made an organizational commitment to adapting and adopting best practices to promote the delivery of effective practices for deaf and hard of hearing consumers. They worked internally in their organizations, supported by coaching from Core Team members, and also came together quarterly to learn from each other. This combination allowed for action to occur steadily within each organization as well as opportunities to celebrate successes and hold each other accountable for making progress on their organizational changes.

 

Conclusion

The Colorado Daylight Project’s approach to transforming the behavioral health system for the deaf and hard of hearing in Colorado is worth watching – this comprehensive and culturally competent effort is well underway to achieving its goals. Want to learn more and think about how to implement a similar systems transformation in your community? Below are resources that can help you!

  • For more information about the Colorado Daylight Project please visit the website, or contact Mary Sterritt, MSW, LCSW at mary.sterritt@mhcd.org, 720.949.7484 (videophone), or 303.504.6521 (voice).
  • For more information about the strategic planning process used in the Daylight Project, please contact Jewlya Lynn, the facilitator, at jewlya@sparkpolicy.com.

 

 

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Children, Trauma, & The Aurora Shooting

Children of all ages will have questions about the Aurora shooting – some around trusting others, others about the safety of going to the movies. Whatever the questions, there are two important things to keep in mind as you talk to a child about trauma:

  1. Tell the truth; and
  2. Keep the discussion appropriate for the development level of the child.

It can be hard to tell the truth when the truth is ugly, just as it can be hard to know the right developmental level.  Today’s blog focuses on examples, ideas, and resources for talking to children about the shooting.

Mother and Child

Having an Age-Appropriate Discussion

Most adults need a little help figuring out the right way to talk with children about tough topics. Fortunately, there are some resources and simple tips for initiating discussions with different age children. Here are some ideas:

Children Under 6

  • Keep explanations simple and broad: There are good guys and bad guys. The police and fire department are good guys – they are there to protect us. They can’t be everywhere but are there when you don’t even know it. Sometime bad things will happen and the good guys are there to help us feel safe again.
  • If they want to do something to help: Help them create a Thank You card for the good guys or a Feel Better card for victims.
  • Media Coverage: Limit media exposure. Many small children watching the 9-11 tragedy thought that there were multiple building being blown up all day long because they didn’t understand they were seeing the same  image repeatedly throughout the day.

School-Aged Children

  • Explanations: Stick to the facts. What exactly happened? We may never know everything that happened or why, but encourage your child’s discussion or play that may help process what they have heard or seen. Make sure to recognize any good things that came out after the trauma: people helping people get better, making donations, community building and support of police and fire officers.
  • If they want to do something to help: Consider partnering with your child on creating or attending fundraiser, making a donation to a hospital, or working with your child and friends to organize a snack basket for the local 911 call center, fire house, or police officers.
  • Media Coverage: Limit media exposure. Repeated images of the violent incident, the perpetrator or bloodied people running from the theater may promote an unintentional fear of going to the movies, or in this case, of college age men with dyed hair or other non-traditional personal styles.

Adolescents

  • Understanding teen behavior: A trauma might make kids feel the world is not safe. Teens may shut down or act out as a means of expression. Therefore, do what you can to encourage discussion and maintain regular activities and structure. Model behavior you want to see from your children, such as journal, open discussion, reading, getting involved in a community activity of healing or some other physical activity that lets your teen feel they have helped in some way.
  • Media Coverage: Limiting media coverage is still important for adolescents. Linda Ligenza, LCSW, Clinical Services Director, National Council for Community Behavioral Healthcare, warns of re-traumatization. “This can inadvertently occur through repeated watching of news reports, reading about the tragedy in newspapers and on line and through hearing and reading inflammatory, disturbing language such as use of the word, “massacre”.”
After the First Discussion

Having a single conversation with a child and limiting media coverage may not be enough. The National Association of School Psychologists recommends these tips for supporting children and youth after a crisis event.

  • Be reassuring
  • Be a good listener and observer
  • Monitor the news
  • Emphasize resiliency
  • Highlight people’s compassion and humanity
  • Maintain as much continuity and normalcy as possible
  • Spend family time
  • Do something positive with your children to help others in need.
  • Ask for help if you or your children need it.
  • Communicate with your school.
  • Understand the grief process.
  • Be aware of your own needs

For more information about each of these tips, and clues about how to use them, visit National Association of School Psychologist’s Resources page.

 General Trauma Resources
  • When Children Experience Trauma: A guide for parents and families, American Psychological Association, National Association for the Education of Young Children. http://actagainstviolence.apa.org/

 

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This is going to take us 10 years! What do we tell our funders now?

Many things worth doing cannot be done quickly. Changing public policy systems, building communities, tackling complex social issues, and advocating for meaningful change are not things one undertakes and completes in a single year, three years, or sometimes even in ten years.

Yet, at the same time, we all have funders and our funders need to know that they are funding organizations that are making a meaningful difference – not ten years from now, but today. Not to mention that it would also be helpful to our long-term efforts if we could figure out whether today’s activities are making a difference for tomorrow.

This is where strategic roadmaps and interim outcomes come in. Yes, the terms are full of jargon, but they are worth learning because they can help you and your funder understand whether what you are doing really does matter and help you do good, even better.

Is what we’re doing today going to matter tomorrow?

Strategic Roadmaps are a powerful tool for taking a complex problem and breaking down the solution into a series of meaningful, smaller changes on the way to the big success. They  are similar to Theories of Change, but provide a higher level of detail and focus on interim outcomes. At Spark, we use them for evaluation (where the concept first came from), but we’ve also adapted them to be a strategic planning tool.

The first thing you figure out in a roadmapping process is where you’re going to end up. It’s a lot like a vision statement, only you want to be very concrete and realistic. Don’t say that you’re going to eliminate obesity. Say  you will increase the number of residents who meet recommendations for physical activity, fruit and veggie consumption, and caloric intake (this is straight from the Stapleton Foundation’s be well initiative roadmap). Or, instead of saying you’ll cause all schools to purchase all of their food locally through farm to school programs, say you’ll cause collaborative, sustainable implementation of farm to school statewide (this one is from the Colorado Farm to School Task Force’s roadmap).

Once you know where you are going to end up, you map it backwards – asking yourself step by step what has to be in place to get to where you want to go. That’s how you know whether what you’re doing today will directly contribute to achieving the end of your road – because you can visually show the road you’re on and how one thing steadily leads to another until lasting and meaningful change is achieved.

For more information about what a Strategic Roadmap process looks like, visit our blog on How Groups Become Change Agents.

How do we know if what we’re doing is getting us to where we want to go?

Here is where the concept of interim outcomes comes in. When you know where you want to end up, and you know what has to happen each step of the way to get there, you’ve just defined your interim outcomes. Let’s back out of that jargon for a minute though and instead just talk about two things: control and influence.

The things you do every day – the meetings you host, the number of people you screen, the trainings you convene, the legislators you talk to – these are things within your control. Sometimes we get into the habit of just reporting to our stakeholders and funders a laundry list of things we did, things in our control. We might tell people we talked to 10 legislators, recruited 50 people to attend our meeting, or screened 200 residents. Careful though, those aren’t outcomes! They are just counts that tell you what you’ve been up to.

Then there are all the things we can’t control, but that really matter to us – the things we are constantly trying to influence. They are things like how a legislator votes on a specific bill, what the 50 people at our meeting think about the issue when they walk out the door and the actions they commit to taking, or the number of people we screened who followed up with their doctors. We work hard to cause these things to happen, but at the end of the day, we can only hope to influence them. We aren’t inside people’s minds, we can’t force these changes and actions to occur. This is what makes them our outcomes.

So what is an interim outcome? It is an outcome that is along your road. You need it to happen in order to get a little closer to that big, long-term goal. But it isn’t something you can control. Are you trying to increase the number of residents meet recommendations for physical activity, fruit and veggie consumption, and caloric intake? Your interim outcomes might include completion rates of residents attending your programs, increases in physical activity level, or increases in knowledge about healthy eating and active living. These are things that matter, but they don’t matter in and of themselves, they matter because they are supposed to be leading to the end of your road.

Strategic roadmaps and interim outcomes sound great, but how do I use these with my funders?

If you know your end of the road and your interim outcomes, you are in a great position to sit down with your funders and talk to them about why your work really matters. You can also work with them to agree on which interim outcomes are achievable within their funding period and could be part of an evaluation. When you’re having this conversation, don’t forget to include capacity building as an important outcome they should support and evaluation should capture. If you are trying to do something that will take three, five, or ten years, you need to build the organizational capacity to do the work for the long haul. Here are some quick tips for talking with your funder about long-term change:

  • Bring a visual of your roadmap and walk through it with them in person. They may challenge you on assumptions you’ve made about why one thing will lead to another, but they will respect the effort you took to map out how you are getting from where you are today to a big and meaningful change.
  • Circle the outcomes on your visual that you think can be achieved during the funding cycle. Talk to the funder about why those are realistic in the timeframe, but other interim outcomes are not.
  • Focus the conversation on the outcomes you’ll achieve, not the activities you’ll use. Anyone can implement a community meeting or host a training. Stand out by showing the funder you are an organization who really knows how to cause change in an individual or a community.
  • Don’t go into the conversation alone. Instead, bring your community leaders, volunteers, advocates, or organizational partners to reinforce their belief that the road you are on will make a difference. We don’t try to cause meaningful changes alone, so there is no reason to be by ourselves when we attempt to secure the funding we need to make a difference.

 

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Family Engagement in Policy and Governance Boards

Nowadays, family involvement is a pretty big buzzword. What does it really mean, though? It is certainly true that human services agencies, community agencies, and other organizations are increasingly interested in recruiting family and youth partners into their decision-making processes. It is also true that research supports the notion that family engagement is associated with positive outcomes for youth, families and systems. That’s all well and good, but when it comes to moving past the very basic “We need more families involved!” to something more concrete, there are misconceptions. Let’s explore the subject…

 

Family Engagement in Colorado

Did you know that Colorado is lucky enough to be fairly progressive in the family involvement arena? Family engagement is written into the Colorado Prevention Leadership Council and Early Childhood State Plans. The state was recently awarded a System of Care grant and many child and family serving systems are changing practices to be more receptive to the family voice. Colorado’s organizations are in the midst of a shift in culture and practice. In short, this needed change is upon us.

A practice change to include families more thoughtfully is equally good for workforce / line staff as well as for the systems in which they work. Families and youth consumers bring a perspective that staff members do not have: their lived experiences as beneficiaries of services and systems. As consumers of services, they will know the barriers and benefits first hand. This is true for board representation, as well as for coalitions and committees. Staff is unable to know their system like a recipient or consumer can, even if they are parents themselves.

“The system building process that fails to develop meaningful partnership with the constituency that will depend upon the system is inherently suspect and limited in its capacity to build an effective system.  Meaningful partnerships with families and youth require concerted attention, dedicated resources, and capacity building across all parties.” Sheila Pires, 2002

The rest of this blog provides a few definitions related to family involvement and outlines ways that our child and family systems (mental health, public health, child welfare, schools, juvenile justice) can support family partnerships.

 

Defining Key Terms

Colorado advocates and system partners have worked alongside families to formalize a working Colorado definition for Family Advocate and Family Member. These terms are intended to cross systems and offer a baseline of expectation and role clarification.

  • Family Advocate: According to the Colorado revised statutes (27-69-102) a “Family Advocate” means a parent or primary care giver who has been trained in a system of care approach to assist families in accessing and receiving services and supports; has raised or cared for a child or adolescent with a mental health or co-occurring disorder; and has worked with multiple agencies and providers.
  • Family Member: As defined by the Colorado System of Care Collaborative, a “family member” is a person who is raising or has raised a child, youth, or adolescent with special physical, mental, emotional, behavioral, substance use, developmental, and or educational needs. They have direct experience in working with many of the agencies and providers in their community and can provide valuable insights by serving on state and local boards, committees, and coalitions. They also can also be hired as Individualized Service Plan care managers and/or facilitators, family advocators, evaluators, and trainers.

 

Readiness Self-Assessment

Are you ready to bring on family partners? Is your board or committee ready to take the steps to change practices (by-laws and voting protocols) to enable full participation and voice? If you are on a board or committee that would like to include family and/or youth members, the Board Self-Assessment on Family and Youth Involvement is for you! This is a free self-guided tool that provides a succinct way to capture your group’s readiness, areas of strengths, and opportunities for improvement in order to transform the group culture to one that welcomes consumer’s ideas and sustains their involvement.

The results of the self-assessment point the user to specific sections within the Family and Youth Involvement Workbook for Policy and Governance Boards and Planning Groups , pointing out examples, worksheets, and talking points to help you move your organization towards a more inclusive place.

 

Listening to Families

In 2008 Spark conducted focus groups with families involved with Colorado’s child welfare, mental health and juvenile justice systems in 2008. Family members who have been working with systems suggested the following ways to create involvement opportunities for families and consumers:

  • Incorporate requirements around family involvement in requests for proposals;
  • Maintain and promote family and youth advisory boards; and
  • Create and adopt a process to evaluate the success of staff efforts to engage families and youth.

Family members also suggest the following strategies to make your meetings more family and youth friendly:

  • Hold informational meetings at existing events in communities;
  • Have meaningful, action-oriented meetings and roles for families to contribute;
  • Have family & youth members help identify agenda items for the meetings;
  • Provide food and /or childcare available whenever possible;
  • Have the various organizations bring in resources, information, and linkages to their programs; and
  • Use rules that are less formal and complicated than Roberts Rules.

 

More Resources

Besides the Family and Youth Involvement Guidebook, there are plenty of other resources out there to help you bring the family voice into your decision or policy-making effort. Here are just a couple:

  1. This six page document from the National Federation of Families for Children’s Mental Health helps to identify authentic family involvement at a systems level, beyond just the presence of family members at meetings.
  2. Center for Juvenile Justice Reform: Safety, Fairness, & Stability For Youth and Families —Recommendations to Strengthen Federal Agency Support of Family Engagement Efforts, 2011 Georgetown University.

Also, check out the family and youth involvement section of the Igniting Change resource website for information about training families and youth to participate, engaging them in systems transformation, and engaging them in evaluation.

These suggestions and tips are another way to build off the great work happening in Colorado!

 

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Resources for Igniting Systems-wide Change

Change agents throughout our country are transforming service delivery systems – they are changing how human services, health, and mental health provide care. Some of these transformations go by the name of Medical Home and others call themselves Systems of Care. Regardless of the name, transforming systems is a difficult process. As you undertake transformation in your community, knowing where to go for resources and which models are the best fit can pave the way for successful change.

 

Defining Systems Transformation

At its most basic, systems transformation is changing the way that a service delivery system does its business in order to improve outcomes for its participants. How is that different from systems building, you might ask? ((For a general overview of what is involved in a good systems building effort, please see our previous blog: Why Should We Focus on Building Systems Versus Programs?))  Well, most systems transformation models attempt to pull together and integrate the disparate parts of a particular set of service delivery systems under a new set of values – a new set of guiding principles, or philosophy, for all the service delivery systems with a shared population focus. These new principles usually describe the quality of the services that the entire big new system should offer. Having outlined the guiding principles, most systems transformation models then get into the concrete systems building activities that are needed to bring about the new guiding principles.

 

Systems Transformation Models

Spark’s new Igniting Change website has tools and resources on a variety of systems transformation models – resources ranging from background reading to examples to concrete toolkits on systems transformation.

There are many models out there for systems transformation. It is true that most originate from a particular health or human services sector,
but it is also true that most models can be and are adapted to other systems with relative ease. For example, the Systems of Care model of systems transformation was first developed with the population of children with serious emotional disorders in mind and later expanded to all systems that serve children and their families.

 

Medical Home

The medical home model, also referred to as the Patient-Centered Medical Home (PCMH) approach envisions comprehensive primary care through the creation of a partnership between patients, physician and in certain situations patient’s families. This model of systems transformation allows for better health care, increased satisfaction and better health outcomes.

Here are a few of the resources on Spark’s Igniting Change website related to the medical home model:

 

System of Care

Similar to the medical home model, Systems of Care is a specific approach to systems transformation. As we mentioned earlier, although systems of care is originally from the mental health system, it can be applied to any system serving children, youth, and families.

[blockquote]“A system of care incorporates a broad array of services and supports that is organized into a coordinated network, integrates care planning and management across multiple levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery and policy levels.”   Building Systems of Care: A Primer[/blockquote]

There are many resources on Spark’s Igniting Change website relevant to building systems of care. These tools provide background information, examples, and concrete toolkits on this approach to systems transformation. For example:

  • Building Systems of Care: A Primer by Sheila Pires is a technical assistance tool for state and local stakeholders engaged in developing systems of care for children with behavioral health disorders and their families (but relevant to many other populations as well!). This Primer will provide you guidance on developing over 30 critical systems of care functions that require structure, such as governance, care management, financing and quality improvement, and examines the pros and cons of different structural approaches.
  • The National Child Welfare Resource Center for Organizational Improvement’s Primer Hands on Child Welfare, a web-based training resource for system builders working for children, youth and families involved, or at risk for involvement with the child welfare system. This includes all key stakeholders from families, youth, providers, natural helpers, frontline staff, supervisors, county managers and State administrators, judges, court appointed special advocates, guardians ad litem, law enforcement personnel, policy makers, researchers and evaluators, technical assistance providers, advocates and others.

 

Five Tips for Systems Transformation

  1. Don’t start from scratch.  There are great models and resources to guide your work.
  2. Make sure the values match.  When you pick the model that can guide your systems transformation, make sure you and your community of stakeholders can agree with the values.
  3. Start from where you are at.  Sounds obvious, doesn’t it? But sometimes we want to start with significant change, when small changes are all that our system is ready to undertake.
  4. Celebrate along the way.  Systems transformation is not a one year effort, three year effort, or even a five year effort. It can take a decade or more. That doesn’t mean significant, meaningful change won’t happen every year you work on it. Celebrate those changes!
  5. Ask for help.  Systems transformation communities throughout the country are excited to provide their insights and guidance, along with national technical assistance centers.