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Mental health is not FedEx.

Mental health care is inherently messy.

And – if the need for services overwhelms chronically under-staffed providers many of whom are not well prepared to serve children

And - if budgets are inadequate and reimbursement rates punishingly low

And – if there is a deeply ingrained stigma preventing people from getting help for their children before their situations are falling apart

What can be realistically hoped for?

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I have never despaired … because I have never hoped.

http://www.youtube.com/watch?v=9K30e9O3Nng

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1. Analyze a system of care’s vulnerability to three major threats:

1. Diffusion of responsibility; 2. Organizational inertia; and 3. Organizational entropy.

2. Identify ways of making a system of care robust.

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What system of care problems can be inferred from Jose’s case?

Assume you are the Director of Maternal, Child and Adolescent Health in the county serving Jose and his family.  You decide to call a meeting to address the problems Jose’s case highlighted.  Who would you invite?

Assume everyone is very interested in making sure there are no more Jose’s.  Despite everyone’s good intentions, what serious challenges will the county face in trying to avoid a similar scenario in the future?

What system of care problems can be inferred from Jose’s case?

Assume you are the Director of Maternal, Child and Adolescent Health in the county serving Jose and his family.  You decide to call a meeting to address the problems Jose’s case highlighted.  Who would you invite?

Assume everyone is very interested in making sure there are no more Jose’s.  Despite everyone’s good intentions, what serious challenges will the county face in trying to avoid a similar scenario in the future?

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Have you experienced cases like Jose’s?

1.Yes, just as bad

2.Yes, but not nearly as bad as Jose’s case

3.No

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Have you ever participated in a system of care meeting with leaders trying to address a case like Jose’s?

1.Yes, it was fully attended

2.Yes, but we did not have everyone we needed at the table

3.No

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If “yes” to the system of care meeting, how would you describe the outcome of that meeting?

1. We made real progress. Positive changes came of it.

2. Mixed success. There were some changes for the better but nothing really significant and enduring.

3. We tried but nothing really changed.

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Also know as the “bystander effect”

When an individual is part of a group, they do not feel responsible to act when something goes wrong. That same person, if alone, often will step in.

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Where in a system of care might a diffusion of responsibility creates cracks through which children and families might fall?

Break it down by age group.◦ 0-3 ◦ 4-5◦ 6-12◦ 13-18

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An object at rest … An object in motion …

An organization that is being asked to change or initiate something new will experience organizational inertia.

In your plan which organizations are being asked to change?

How much inertia will the system of care encounter?

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Entropy – the tendency for things to break down over time.

What in a system of care can break down over time?◦ Critical relationships – retirement, moves,

promotions◦ Loss of institutional knowledge – retirement, etc.◦ Changes in support – funding, space, political will◦ ?

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Each community and each situation is unique but …

1. Build relationships across organizationsHelp organizations and individuals own the System of Care (use training events, convene the leaders)

2. Establish clear expectationsWrite things downRead the Checklist Manifesto

3. Provide feedback, especially early on

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4. Celebrate success

5. Recognize individuals

6. Address breakdowns in a blame-free way

7. Help providers benefit from participation – high quality training, fewer no shows, effective referrals, timely information and feedback; better enrollment in programs

8. Position people on the front line to revise the system of care from their experience

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Common Ground◦ Everyone wants to have a really good system of

care for children.

Relationships, Relationships, Relationships◦ Make time to get together with people and get to

know their situation. And, let them know that you understand.

Challenge and Support◦ Go hard on the problem; go soft on the people

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