All of us working in human service organizations are doing what we do not just to be able to say that we run a tight, quality program but to be able to know that the people we serve have better lives because of the work our teams do. It has become obvious to me through many years that if I take seriously the responsibility of helping improve life outcomes for clients, I need to look at systems change that supports families and communities and not just at whether mental health programs provide good enough treatment, though that too remains important. But changing complex systems is an immense challenge even where there is a considerable consensus that change needs to happen. In this editorial, I hope to use two complex systems-change efforts that are playing out in Los Angeles County to illustrate some of the leadership competencies that must be engaged to have the desired changes actually occur.
CHALLENGE #1: INTEGRATING CARE
The first challenge, integrating care, is perhaps one of the hardest facing our nation today. Even those of us with excellent health insurance may have experienced personally, or through caring for loved ones, that getting specialty and primary health care connected and coordinated can be extremely difficult and time consuming. This general issue is even more difficult for those who suffer from mental illness. As a result, people with serious mental illness die more than 20 years earlier than the general population, not due to the effects of mental illness such as suicide, but from chronic health conditions like diabetes and heart disease.
What are the policy and systems issues that make care integration so difficult, and how do we go about changing them so that we can have a real impact on health outcomes? One of these policy issues is the hyper-specialization of our health care system and the absence of a payment mechanism for the care coordination necessary to tie together the subspecialties. For a brief personal example, I experienced pain recently in my upper right shoulder. After examination, my primary care physician referred me for physical therapy on my neck and shoulder. But the therapist for the neck wouldn’t see me with a referral that included shoulder pain nor would the clinic for the shoulder pain see me if the neck pain was included. By the time I got the referrals sorted out, the pain had gone away on its own. But it was remarkable that the emphasis on specialization, even in kinds of physical therapy, can serve as an obstacle to care.
Another example of a policy challenge is that in our Los Angeles County Mental Health system we are reimbursed by Medicaid for a variety of case management and advocacy services under our waiver, but we are told that case managing the physical health care for our clients is not reimbursable. Further, there are specific federal confidentiality standards for substance use treatment that make care integration complicated.
An even greater policy challenge presents itself if we focus on creating better health outcomes from the services that get integrated. The literature on the social determinants of health outcomes indicates that 20% of the variance in health outcomes results from access to quality health care; another 10% comes from brute environmental factors such as pollution and air quality; 30% results from personal health habits such as diet, exercise, smoking and alcohol use; and the remainder of the variance, 40%, comes from the social environment of the community in which one lives. So that if one wanted to predict an individual’s longevity and had only one piece of information, the most valuable single thing to know would be the person’s zip code. In Los Angeles, the difference in longevity between the healthiest and the least healthy zip code is a shocking 17 years.
In addressing the challenges of care integration and wrestling with the social determinants, the Los Angeles County Department of Mental Health has attempted to lead systems and policy change by adapting a concept called Health Neighborhood, used in Seattle and other places, with circumstances similar to that of Los Angeles. The 12 pilot Health Neighborhoods we have developed operate at two levels: First, they are a consortium of the primary care, mental health providers, and substance abuse providers serving a particular community (Central Long Beach or Boyle Heights, for instance) who agree to share information about common clients using a common consent form and other protocols. But at a more profound level, the goal is to embed these treatment agency consortia into a community empowerment effort with the idea of motivating communities to take action on the social determinants of health outcomes. Then two things happen, presumably the social determinant the community works on improves, but also the very act of the community working together on its own behalf improves its health outcomes.
I should be clear that all of the Health Neighborhoods in the initial implementation phases are being grafted onto existing community empowerment efforts because the process of doing that community organizing effort is very time-consuming. Fortunately, Los Angeles is rich in these kinds of efforts funded both by governmental and philanthropic sources.
So what might we say about the leadership competencies required to make this effort successful, and which competencies might need to be strengthened? For the purposes of this discussion I am using the leadership competencies identified by the National Network for Social Work Management.
In terms of key competencies like “vision and philosophy” and as an “innovative change process,” Health Neighborhoods have been well received. The concept, both in the form of the treatment consortium and community empowerment effort, has inspired a great deal of enthusiasm. It has been included in the County Strategic Plan, has been funded by foundations for conceptual development, has been the subject of successful academic proposals for formal research on its development and outcomes and garnered sufficient resources to offer concrete benefits to communities, and most importantly, has been well received by the grassroots community empowerment projects.
The leadership in Health Neighborhoods has also succeeded fairly well in its efforts to actively engage staff and stakeholders in the decision-making processes. Federally qualified health centers (FQHCs), health plans, the mental health and public health leaders, and grassroots community members and faith communities have come together in the planning and implementation process. In some areas, municipal governments county agencies are committed participants. Further, the community empowerment structures in each of the communities will be making the decisions about which of the social determinants to address in each particular community.
The most challenging competency to undertake in this project is the development and management of stakeholder relationships. Some work in this area has gone extremely well. The academic community, grassroots community members, faith communities, health plans, foundations, public health population–based programs, FQHCs, substance abuse providers, and mental health providers have all been engaged and enthusiastically participating in the development process. But more attention needs also to be paid to the publicity and the political skills needed to strengthen the stakeholder-political relationships necessary to make Health Neighborhoods succeed. Despite all of the enthusiasm and willingness of partners, there are those in the health community, particularly some with institutional commitments that are not community based, who may not see Health Neighborhoods as a first priority. Leadership must prioritize efforts to publicize the benefits of the Health Neighborhoods broadly so that public support will build—and with that public support, the political commitment to overcome such obstacles as may arise. Failure to mobilize more political capital will relegate Health Neighborhoods to being just another “pilot program” and not the systems-change effort it is meant to be.
So the leadership competency assessment for Health Neighborhoods: Vision and partnership with the community in decision-making are well developed and stakeholder partnership is coming along, but the publicity and political dimensions of managing stakeholder relationships need more attention if the longer-term development of Health Neighborhoods is to succeed.
CHALLENGE #2: ADDRESSING OVERINCARCERATION
The second leadership challenge we will consider is the overincarceration of individuals in this country. Malcolm Gladwell has eloquently described the unintended devastation to communities brought about by efforts like California’s Three Strikes law as one manifestation of this problem. This issue of overincarceration is particularly worrisome when it attaches to persons with mental illness. The systems and policy underpinnings of this problem are complex. In California, the Three Strikes law was a significant factor especially when combined, as it was, with an insufficient alcohol and drug treatment system (especially considering the Medicaid benefit for such treatment), a policing policy that treated some minority areas as occupied zones instead of communities, high housing costs coupled with low wages, insufficient high intensity mental health services, and difficulty in mandating involuntary treatment. Many of these conditions have changed or are changing. Three Strikes has been repealed and California Proposition 47 has reduced the penalties for many drug-related offenses, a generous alcohol and drug Medicaid benefit is being developed, an Assisted Outpatient Treatment law for those who need but refuse mental health treatment is being put in place, and more appropriate policing strategies are being implemented. Yet there remains a problem: despite all of these changes the numbers of mentally ill incarcerated in the Los Angeles County jail have remained constant even as the overall jail population has decreased.
In Los Angeles, a serious effort to divert persons with mental illness from the justice system is underway, initiated by the Department of Mental Health and led by the district attorney. The vision is comprehensive: It plans to train law enforcement personnel to convey persons with clear mental illness who have committed relatively minor crimes to treatment facilities at which they can be assessed and connected to the proper kind of mental health or addiction treatment. For those with mental illness who have been arrested, there is to be a systematic review with the public defender and the district attorney to see whether referral to a treatment facility rather than incarceration might be recommended to the court as better serving the public good. For those arrested and sentenced to jail time, an evaluation is conducted of those who deteriorate mentally under the stress of confinement concerning whether other options might be available. For those with mental illness or addiction who have completed their sentence (indeed eventually for all who are leaving jail), we are developing a comprehensive discharge plan that addresses physical health, mental health, and substance abuse treatment needs along with housing and employment arrangements. And finally, the plan is to create in the communities to which incarcerated individuals return (perhaps using Health Neighborhood as a vehicle) the support for different activities and life choices that are crucial for avoiding recidivism. This may also include training mental health treatment agencies on the evidence-based practices that will help returning inmates adopt new habits.
This comprehensive vision is already partially in place. From prebooking diversion to community activated support systems, Los Angeles County Department of Mental Health already has these operational programs. There are two problems: The first is scale—in none of these plans are the resources sufficient to deal with the numbers of individuals involved. Our implementation problem is that Los Angeles County is often one of scale because despite numerous outstanding programs, it is often difficult due to our size to support the comprehensive change that creates a system that makes sense. The second problem is that housing and employment are challenging matters everywhere in Southern California but particularly in the neighborhoods to which former inmates return.
Because the elements of this vision are already operating, the basic stakeholder partnerships that support how this work ought to be carried out are well developed. Unlike in the Health Neighborhood initiative, there are clear models to follow; therefore, the leadership challenges are somewhat different. There is robust political support and media coverage of the plan and its challenges. The primary leadership challenge in this arena concerns the nature of the stakeholder relationships that need to be maintained. All of the partners believe that “diverting mentally ill from jail into treatment” is a great idea. The problem is that different partners mean different things by diversion. Some in the justice community imagine diversion means locking folks up in hospitals instead of jails, some in the family movement envision all charges being dropped, others desire that charges be held in abeyance to compel participation in treatment, some among treatment providers see addiction rather than mental illness per se as the primary issue, and finally some communities are fine with diversion as long as these individuals are diverted to someone else’s community. Sorting out these perspectives and keeping the coalition together will be an important leadership competency to develop.
I have focused specifically on the leadership domain of the Network Competencies for Public Sector success in the Health Integration and Diversion discussions, but there are important skills necessary from other competency domains that need to be applied in major systems-change efforts like these. The difference is that these need to be applied to a wider field of action than the concerns of a single agency. For example, in the domain of resources management, the human, budgetary, and technology resources of an agency need to be managed. But they need to be managed with an eye to the goals of the overall collaborative and not just from the perspective of one’s own organization. Similarly, strategic planning is, of course, crucial; but the planning needs to be dual, taking into account the well-being and future trajectory of one’s own agency and also the common goals pursued by the collaborative in the systems change. Balancing the particular interests of one’s own areas of responsibility with the demands of the opportunities inherent in the change process requires building and maintaining the skill sets for community collaboration among all of the partners.
CONCLUSION
Anyone attempting to exercise leadership in important policy matters such as the two I have described must develop certain competencies that include a plan that calls for attending to conceiving and articulating a vision and a philosophy that support a comprehensive change process, assembling and motivating reliable partners as stakeholders in the process, understanding the cultural and communication skills necessary for the completion of the tasks involved, securing the political support by stakeholders through public engagement using publicity for the process and the outcomes, and finally insuring continuity by promoting mentoring of new leaders for the next phase of development.
Different projects at different stages of development will require a different mix of these competencies as the projects progress. It is my analysis that the Health Neighborhood initiative requires more attention to the political and publicity dimensions of its stakeholder development while for the diversion project to be brought to meaningful scale will require more attention to the nature, quality, and expectations of the partners needed to bring it about.
One last note, the leader needs also to be on the alert and prepare in some fashion for the “black swan” that is the totally unexpected event that could come out of nowhere and change all expectations and calculations. It’s not that anyone can prepare for such events; it is just that knowing of their possibility calls for adjustment in the overall process of trying to lead important change.
Related Research Data
