The second panel, moderated by Mary Pittman, the president and chief executive officer of the Public Health Institute, provided examples of spread and scale from other sectors. Pittman referred participants to several recent articles on scale and spread that cut across different sector approaches. Lavinghouze and colleagues, for example, described the need to have program-level capacity to effectively implement and sustain programs within a larger public health infrastructure (Lavinghouze et al., 2014). Both governmental and nonprofit public health infrastructure has been underfunded for years, Pittman said. Should the existing infrastructure and programs continue to be funded, she asked, or should the infrastructure and programs be designed differently in order to achieve scale and spread of innovations and solutions? In one publication, Lublin and Finger of DoSomething.org described how, in an effort to scale, the organization decided to cut half of its programs and instead focus on campaigns for issues in which young people are engaged (Lublin and Finger, 2014). While the approach was transformative, Pittman questioned whether it is sustainable for change.
Panelist Linda Kaufman, the national movement manager for Community Solutions’ Zero: 2016 campaign to end homelessness, shared lessons learned from the spread and scale of the 100,000 Homes Campaign to reduce homelessness. Ogonnaya Dotson-Newman, the director of environmental health for West Harlem Environmental Action, Inc. (WE ACT) for Environmental Justice, discussed strategies from the environmental justice movement. Dan Herman, a professor and the associate dean for
scholarship and research at the Silberman School of Social Work at Hunter College, described scaling the Critical Time Intervention (CTI) model of support during high-risk transition periods, with the goal of reducing recurrent homelessness. (Brief background information on the case examples, including how speakers understand spread and scale in the context of their own work, was submitted by the panelists prior to the workshop and is available in Appendix C.)
“I believe housing is health care,” Kaufman said, and “we cannot do health care without housing.”1 During its 4-year 100,000 Homes Campaign, Community Solutions worked with 182 communities around the country to house more than 100,000 vulnerable and chronically homeless individuals and families by July 2014. This national movement has reduced veteran homelessness by 33 percent and has reduced long-term homelessness by 20 percent, Kaufman said. Today, Community Solutions is no longer satisfied with simply reducing the amount of homelessness, she said, but instead is focused on reducing the number of homeless to zero. The Zero: 2016 initiative is a follow-up to the 100,000 Homes Campaign, and is intended to help 71 communities in 4 states end veteran homelessness by the end of 2015 and to end chronic, long-term homelessness by the end of 2016.2
Kaufman outlined the five basic steps in the 100,000 Homes model: build the local team, clarify the demand (and triage the placements), line up the supply (i.e., the housing), move people into housing, and help people stay housed. The model was developed and piloted in Times Square in New York City and then was spread to five other communities (Albuquerque, Charlotte, Denver, Los Angeles, and Washington, DC). The 100,000 Homes Campaign approach to spread and scale was based on lessons from the collective impact and lean start-up models. Kaufman outlined four basic stages of spread and scale:
- Prototype. Find an idea and start.
- Pilot. Try it, learn from the mistakes, make changes, measure outcomes. The pilot phase was not a straight duplication of what was done in Times Square.
- Spread. Share it everywhere. Community Solutions took the lessons learned from the pilot communities and spread them to more than 200 communities with the 100,000 Homes Campaign,
1 For more on housing as health care, see Doran et al., 2013.
targeting communities with more than 1,000 people homeless, but taking all interested communities.
- Scale. Help communities that are ready to get to zero homelessness among veterans and the long-term homeless.
Kaufman shared some of the lessons that Community Solutions learned in conducting the 100,000 Homes Campaign. First, she said, choose a talented, capable leader, and put together the best team possible. Let the data experts lead the strategy. Dream and plan every 6 months to learn, change, and grow.
One of the most important lessons learned, she said, is that housing should be given out based on the need for housing, not according to how long someone has been waiting. Evidence suggests that about one-quarter to one-third of those who are homeless get out of homelessness on their own; about half need a short-term intervention (e.g., 3 to 6 months of rental assistance), and 90 percent of the time they do not enter the housing system again; and about 15 percent need a permanent housing voucher. The communities that are actually reducing homelessness, she said, are the ones that are triaging the people asking for housing. Communities in the 100,000 Homes Campaign were asked to know every person in their community who is homeless by name and to have enough information to triage them for housing.
Ask communities if they are ready for zero, she concluded. Zero: 2016 has set high standards for communities to be part of the initiative. Communities can do amazing things, Kaufman said.
The 1987 United Church of Christ report “Toxic Waste and Race” was the first report that really discussed the relationship between the geographic proximity of toxic waste sites and communities of color and low income, said Ogonnaya Dotson-Newman, the director of environmental health for WE ACT for Environmental Justice, in New York. This early evidence of disproportionate exposures found that three out of five Black and Hispanic Americans lived in communities with one or more uncontrolled waste sites; that race was the single most important variable (more than income or property value) determining proximity to toxic waste sites; and that the percentage of the local population that was of color increased proportional to commercial waste sites. An updated report 20 years later found that many of these racial and socioeconomic disparities persisted. Host communities for commercial hazardous waste
facilities were located predominantly in communities of color, and there were unequal protections for communities hosting hazardous facilities. Dotson-Newman said that these exposures can create a toxic legacy of heritable health effects that will affect future generations regardless of where they live or what they achieve socioeconomically.
The environmental justice movement is the product of a convergence of civil rights, environmentalism, and public health and is focused on social justice, pollution prevention, and environmental protection. Critical issues include cumulative and multiple exposures, poor and unhealthy land use decisions, the exclusion of the community voice from decision making, and accountability and transparency of public institutions. Many of the ideas and solutions adopted by the movement are coming from grassroots organizations, and many community-based organizations are scraping together materials and resources to begin to have an impact on a day-to-day basis. Dotson-Newman said that it is important to work on multiple levels, engaging with grassroots organizations but then taking ideas to scale in order to achieve measurable results.
WE ACT for Environmental Justice is a northern Manhattan community-based organization whose mission is to build healthy communities by ensuring that people of color and low income people participate meaningfully in the creation of sound and fair environmental health and protection policies and practices, Dotson-Newman said.3 WE ACT is involved in the training and empowerment of people in the northern Manhattan area and in advocacy at the city, state, and national levels. For example, WE ACT will take community members to meet with their city council officials or senators. The organization also has community academic partnerships, such as a partnership with the Columbia Center for Children’s Environmental Health. WE ACT translates molecular epidemiology research into plain language so that community members can use it to advocate for better policy or to take steps to limit their personal exposure.
Spread and Scale
Dotson-Newman shared an example of the spread and scale of an idea and a policy. The 2014 Climate March brought more than 400,000 people to New York City to highlight the need to address climate change. She traced the origins of this action back to 1982, when civil rights and environmentalism came together in an environmental action at a landfill in Warren County, North Carolina, that contained polychlorinated biphenyls, or PCBs. That early work by individual groups working locally
grew to a focus on issues that affect low-income and communities of color at a national level. Together, by working at local and national levels, they were able to push for an executive order signed in 1994 (Executive Order 12898) focusing federal attention on issues of environmental justice and health. This led to growth in many areas, from communities increasing awareness and organization and government agencies considering health disparities in their rule making, to researchers partnering with community-based organizations to better understand their health needs and more individuals becoming trained in organizing to create change.
CTI is an individual-level, time-limited care coordination model that mobilizes support for vulnerable persons during periods of transition. Herman explained that the work actually began in the 1990s in the Fort Washington Armory in upper Manhattan, which at the time was serving as a large shelter for homeless men. Up to 1,000 men would sleep on cots on the drill floor of the armory, many of them suffering from mental illness, substance abuse, and untreated medical problems, including HIV and tuberculosis. Over time, some people went into supportive housing units, others were able to be reunited with family members, and others found rooms on their own, often with the help of social services staff. Unfortunately, Herman said, it was observed that many of the people placed in housing cycled back into the shelters or to other institutions. The CTI model evolved up from street-level workers eager to provide better support and to increase retention in housing.
CTI is a model of how to provide support during high-risk transition periods with the goal of improving long-term outcomes. It differs from traditional case management or care coordination models, Herman explained, in that it is explicitly designed to be time limited and to focus on the periods of transition that have been identified through research as being high risk for recurrent homelessness, re-hospitalization, incarceration, or a variety of health risks. CTI workers are taught the skills to focus on individual-level risk factors for recurrent homelessness. The model is applied over 9 months, in three phases of decreasing intensity of involvement with the individual to be housed. The goals are to provide transitional support that links people to long-term supports in the community and to help people become more effectively rooted in the community, thereby reducing the risk of recurrent homelessness.
With funding from the National Institute of Mental Health (NIMH), a randomized trial was conducted comparing CTI for 9 months to normal discharge planning and follow-up services. The study found a reduction of about 60 percent in the risk of recurring homelessness after 18 months
for those in the CTI group, compared to those randomly assigned to housing (Susser et al., 1997). A second NIMH-funded study adapted the model for use with a similar population of homeless people being discharged from a psychiatric hospital, which is another key risk period for homelessness, Herman noted. Again, the study found a reduced risk of homelessness as well as a reduced risk of psychiatric re-hospitalization associated with CTI (Herman et al., 2011).
Spread and Scale
As a researcher, Herman said, his first step in the dissemination of CTI was to publish the results of the first randomized trial in the professional literature. This led to occasional contacts from service providers interested in the model. He noted, however, that publishing scientific research—or creating websites or national registries of evidence-based programs and policies—in the hopes that people will discover the work is not an effective approach to spread and scale.
Herman and his colleagues realized that they, like most intervention developers, did not have the capacity to move the model forward. What evolved, then, was a partnership strategy to disseminate the CTI model, in which Herman and his colleagues worked with nonprofit and for-profit organizations that train social services and health care providers. In 2014, with support from the Silberman School of Social Work at Hunter College, the Center for the Advancement of CTI was launched to support the dissemination of CTI and to promote collaboration among trainers, providers, researchers, advocacy groups, and policy makers.4
In closing, Herman reiterated his concern about the dissemination of evidence-based interventions in social services and health care, including the sustainability of dissemination efforts. While there have been suggestions of linking with commercial enterprises, Herman said he felt that these types of models are not of commercial interest from a profit perspective. What is needed, he asked, in order to develop—and sustain—that infrastructure to help promote effective dissemination? Another concern is that, to be effective, models need to be locally relevant, adapted to fit the unique needs of communities. Herman said that the challenge here is how to allow for adaptation of the model, while preserving the fundamental elements that account for its impact and preventing “model drift.”
Following the introductions of their case examples, participants discussed further how to take local advocacy to scale, the iterative nature of spread and scale, and business models for spread and scale.
Taking Local Advocacy to Scale
Moderator Pittman asked panelists to comment further on advocacy at the local level and on scaling advocacy strategies. Advocacy at the community level is very grassroots, Kaufman said. As an example, she cited the Albuquerque Heading Home initiative to end homelessness, whose tag line is “The smart way to do the right thing.” She noted that the fiscally conservative mayor and the more liberal social services community were able to come together because the initiative both saves money and saves lives. Having accurate information about how much money is being saved by housing homeless people rather than supporting them on the streets gave the advocates leverage with the city.
The most effective advocacy, Kaufman said, is telling the stories. For example, as part of the 100,000 Homes Campaign, before (homeless) and after (housed) pictures and stories were posted online every week, showing the overall improvement of the people. She added that Community Solutions has a communications staff person who works with communities to help them tell their own stories. Community Solutions has also been involved in advocacy on the national level, telling the stories and collaborating across lines and across ideologies. The organization has one staff person who is focused on strategic partnerships with the U.S. Department of Housing and Urban Development, the U.S. Department of Veterans Affairs, the U.S. Interagency Council on Homelessness, and others.
Dotson-Newman concurred, noting the applicability of the phrase “Think globally, act locally.” There are many communities that are dealing with the same issues. A coalition or network of organizations and agency staff needs to come to some consensus around national and local advocacy strategies and implement them. For example, as Kaufman discussed, the 100,000 Homes Campaign has a network of individuals who bring local voices into the national campaign strategy. Environmental justice organizations and public health researchers have been working in collaboration to influence the reform of state chemical policies and then to use those as leverage to get the U.S. Environmental Protection Agency and other organizations to take action and also to hold industry accountable.
Herman added that while issues such as homelessness and environmental justice are cross-sectoral, they are confined to a particular service delivery organization, agency, or funding source. They are community-level problems that can only be effectively addressed at the community
level. Advocacy approaches are essential as they are the only way to mobilize sufficient energy and activity across sectors to address such complex problems.
Spread and Scale as Iterative Processes
Panelists further discussed the concept that spread and scale are iterative processes and that models need to be adapted over time and to the population. Kaufman said that it is important to recognize what is not sustainable. It is also important to be able to let go and to let communities develop their own goals and handle some of the responsibility. For example, Kaufman said, some communities want to give out gift cards as incentives for filling out surveys, while others do not, feeling that this would be a form of bribery.
Pittman asked how variability across locales affects data collection and evaluation. Kaufman responded that there are elements that communities must agree to. For example, to be part of the Community Solutions campaigns, communities must know every homeless person by name, with enough information to triage them. The communities do not have to use the tool provided by Community Solutions to do this, but they do have to have the same end result. For the 100,000 Homes Campaign, communities had to agree to house 2.5 percent of their chronically homeless population every month and to report monthly on how many people were housed. When not all communities were reporting, a “fully committed” list was instituted that contained the communities that did know everyone by name and that reported every month. Communities became eager to be part of this “exclusive club” and to be on the list. This is just one of the ways the program continually adapted to foster progress, Kaufman said.
Business Models for Spread and Scale
Debbie Chang said that at Nemours they learned to be intentional about doing spread and scale and actually created a national office with that focus. Chang asked panelists to elaborate on their business model, including financing for spread and scale. In many cases, especially in social services, the support for developing a thoughtful, effective business model or infrastructure to support the spread of an innovation does not exist, Herman said. There are individual charismatic leaders who have been successful in pulling together resources to support the spread of programs, but there is a gap in the infrastructure that is used to bring innovations to the community to improve health outcomes.
Dotson-Newman suggested that being able to do spread, scale, and
strategic planning is a privilege. Many social services organizations and community-based organizations are necessarily focused on near-term goals, such as keeping the doors to the shelter open or making sure there are enough staff members. These organizations do not have the support to plan for spread and scale. She offered several examples where community organizations did have such support. In one case, the National Institute of Environmental Health Sciences provided strategic funding and support for community–academic partnerships to develop ways to translate science into practical actions (e.g., asthma home management programs). There has also been investment by foundations in the training of the leaders of the community-based organizations on how to develop a business plan and a theory of change. Some foundations have also provided funding for consultants to help with the transition to scale up in the organizations. She cited the Harlem Children’s Zone model as an example of the development and implementation of a strategic plan to spread a successful model.5 Kaufman acknowledged the Institute for Healthcare Improvement for its support of the 100,000 Homes Campaign and continuing work.6 Support for the campaign has come from a variety of places, and she reiterated that there is a staff member whose job is to focus on developing a diversified portfolio of strategic partnerships with corporations, foundations, and the federal government.
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