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Drivers for Improvement and System Change
Throughout the presentations and discussions, various examples of opportunities for change were highlighted. A range of diverse ideas emerged from several different fields, demonstrating the complex nature of the problem, which many presenters noted requires a multifaceted approach. Some of these “drivers for change” as noted by David Willis, senior fellow at the Center for the Study of Social Policy, would be in such traditional areas as allocation of appropriate resources or policy changes, while others are likely less commonly discussed. These less discussed opportunities to drive change include changed mental models, examining power dynamics in a setting or community, and taking a hard look at the processes of certain practices to see if they can be packaged in different ways to better address the needs and improve outcomes.
This chapter provides a summary of the discussions of these examples and suggestions offered by many of the workshop participants. Although many of the ideas do not fit neatly in just one category and are a blend of more than one driver, organizing them by category can be a helpful guide in thinking about how to start a process of change and with whom to work. The rest of this chapter thus covers practice changes, potential policy changes, resources, power dynamics and relationships, and mental mindsets and models.
PRACTICE CHANGES
What may seem like a basic practice change yet is likely not realized in many places around the country is having a dedicated protocol for babies
with neonatal abstinence syndrome. Kelleher commented that about 10 percent of the births in some southern Ohio medical centers are diagnosed with the syndrome, but most places do not have the staffing and resources to handle this vulnerable population. In addition to adequate staffing, he also suggested standard assessment scores so there is a solid understanding of severity and protocols for treatment and discharge.
Similarly, Kelleher suggested, simply packaging reproductive health and treatment services together could reduce the burden for the patient seeking care, as well as promote coordination and awareness of health issues and patient desires on the provider side. While this is a reality in some places, many women still need to seek care and schedule appointments at different centers, using different providers for those services, in addition to what can be a separate process for their health care and the health care for their babies.
Rahil Briggs, national director of HealthySteps at ZERO TO THREE, explained that there is 2016 guidance from the Centers for Medicare & Medicaid Services (CMS) that authorizes states to conduct depression screenings for non-Medicaid eligible mothers for the sake of their Medicaid-eligible child and bill it to the child’s account.1 States may also cover depression treatment when the child is present. This guidance is very explicit, she said, yet it is not really being put into practice in most places. She asked participants to consider how this situation can be changed to do a better job of making this guidance operational. Thompson responded that this is an ongoing challenge, and she hopes, using two Center for Medicare & Medicaid Innovation (CMMI) programs, to really start working with and educating states on how far they can go on coverage and payment strategies to make care more integrated for mothers and children.
POTENTIAL POLICY CHANGES
In considering policy changes, Bacall Hincks noted that though the Family First Prevention Services Act (FFPSA)2 is a spur for discussions about the importance of preserving families and including grandparents, there are often many others who want to step up and be there for the children in need but who do not receive anywhere near the same support as foster families. She acknowledged that FFSPA is beginning to look at funding now for kinship programs similar to the one she described in her
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1 See https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf.
2 FFPSA offers federal support for the prevention of foster care services and creates opportunities to affect change through making available evidence-based services for mental health, substance abuse, and in-home parent skills training to support families. See more at http://www.ncsl.org/research/human-services/family-first-prevention-services-act-ffpsa.aspx.
presentation, but it is a new idea, and progress has been slow. Similarly, tied into both policy and resources, Shelly Sutherland added that anything available that can help more families access programs and funding—especially related to housing and transportation—would be really valuable. In relation to access, she mentioned there has been a decline in use of the WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] program in Montana, even though she and others know the demand has grown during the same time.
Kelly Kelleher suggested a more technical policy change related to data sharing, an ongoing challenge across health care. As a concrete example, he said that drug treatment programs do not share their data with Medicaid when reimbursed through state funds. Additionally, Medicaid does not share the treatment data for medications with the service providers in community health centers. And because his organization is a pediatric accountable care organization, it only receives pediatric claims even though prenatal services are billed through the state managed care programs. Because of this, the Center for Innovation in Pediatric Practice at Children’s Nationwide Hospital is unable to tell if women received prenatal care through the drug treatment facility. He identified a need for a common data pool that is both accessible and available.
Another policy change could include more streamlined prenatal care, Kelleher said. For example, he is unable to bill for long-acting reversible contraceptives during the baby delivery admission, even when a woman requests one, because the rules specify that it cannot be billed as a separate item until the woman is discharged. Segregating the billing for this would allow the intervention to take place at the time of request and prevent another unnecessary trip for a woman to return with a premature baby, among other treatment appointments. Similarly, Kelleher noted, central Ohio currently only has three specially trained obstetricians that focus on pregnant women with substance use disorder, so broadening this group of providers and supporting the connection through policy or incentives could lead to better outcomes.
Another policy change suggestion from William Beardslee, director of Baer Prevention Initiatives, was related to screening for depression in mothers—especially given the high prevalence of depression in low-income, high-risk women. To support this suggestion, Beardslee noted that the U.S. Preventive Services Task Force now recommends screening of depression in adults, including pregnant and postpartum women, because of evidence of its benefit (Siu and U.S. Preventive Services Task Force, 2016). With the Task Force’s recommendation, Beardslee said, the practice should be more widely covered and available through insurance plans, increasing the number of people who are diagnosed and connected to treatment services or other resources.
Finally, Martin Flores offered a different type of policy suggestion to influence change related to the destruction of opioids. He explained that he is trying to use the Deterra Drug Deactivation System3 to do this but would love to see it implemented more comprehensively in the Indian Health Service and among the elders and others in the community. Under this system, if drugs are appropriately prescribed but not used, people are able to destroy the drugs themselves before they fall into the wrong hands.
RESOURCES
During the workshop a few different examples were offered of how additional resources could improve the services available and ultimately the well-being of children and families. Kelleher commented that one of the challenges of grant funding is that the amounts and availability are limited, making the process more of a competition than would be ideal. He said that because of their success and recognition, Columbus and Nationwide Children’s Hospital have been the beneficiaries of some great grant opportunities in the past, but there are people who think they receive too much support and it should be spread to others who have fewer resources. But looking more broadly and at a higher level, he noted, if the funding and infrastructure are not being provided to keep the existing programs strong and intact, then what does that mean for those being helped in the long term? He asked how one can move so that the infrastructure has legal, data, and quality improvement resources behind it in order to be sustainable and efficient in direct programming. Tied into resources, naturally, is policy, and Kelleher noted that policies at the state level could be very influential on this issue.
In another example of blending resources and policy, and adding a third arm of communication, Thompson stressed how much flexibility states have related to Medicaid spending, but that many do not realize how much they are able to do using Medicaid resources. Because some of the regulations are confusing, CMS releases informational bulletins that try to explain some alternatives that are more nontraditional and “outside the box.” Currently, she said, CMMI is working on different Medicaid models and addressing the gap between the authority to implement something and whatever might be stopping states from putting new models into action.
POWER DYNAMICS AND RELATIONSHIPS
Kelleher pointed out that to be successful in such a pervasive and multifaceted issue as opioid use will naturally demand partnerships across
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3 For more information, see https://deterrasystem.com.
communities and levels of government, and one of the fundamental pieces of creating these strong relationships is the type of language used and understanding that words matter—especially in a local environment. For example, he said the term “historical trauma” is not really relevant for many people in Columbus, Ohio, because these communities are experiencing “current trauma” through residual real estate redlining, institutional racism, or other institutional inequities. He said the lack of labeling with controversial terms can be helpful when trying to organize partnerships, especially when everyone has the same goal of helping families and improving the well-being of children. Along the same lines, partners or programs that are typically stigmatized—such as drug treatment programs or centers—need to be seen as equals. The more streamlined and coordinated the entire care process can be for individuals or families who are struggling with addiction and drug use, the less likely they are to fall through the cracks and the more positive their outcomes will be.
Carlos Santos, assistant professor in the Luskin School of Public Affairs at the University of California, Los Angeles, brought up another avenue for shifting dynamics related to those communities that have been targeted through the “war on drugs” policies in previous decades. In terms of drug reform, Chuck Slemp acknowledged that his role as a prosecutor is to follow the law, but there are many other things prosecutors and others can be doing within the criminal justice system proactively. He especially highlighted the need to repair partnerships among prosecutors, law enforcement, community groups, teachers, and young people in an effort to heal these communities.
David Hawkins, endowed professor of prevention in the School of Social Work at the University of Washington, posed a question to the group: “How do you build assets and strengths in individuals, families, and communities in light of what we’re seeing today?” Responses included focusing on building healthy coping skills in youth and thinking about prevention through team building and strengthening young people’s identity. Flores added that just working to engage youth and get them excited about a program will often pique an interest in parents who then want to learn more and get more involved. Sutherland also commented that much of her work at the Bighorn Valley Health Center is centered around positive reinforcement, pointing out what the parents are doing right that can be commended. When working with the entire community, she continued, she and her colleagues also let the parents and participants drive the discussion and ask them what services they need and what they want to see available, instead of doing an external assessment and deciding what would be best for the community without their input. Though it can sometimes be messy, avoiding a top-down approach when working on critical and communitywide issues like these can be more valuable in the long run (Barnes and Schmitz, 2016).
MENTAL MINDSETS AND MODELS
Several topics that arose during the workshop discussions can best be thought of as changing people’s orientations to and relationships with their social environments. This section briefly looks at social isolation, social and emotional learning, reducing stigma, and investing in people.
Social Isolation
Nathaniel Counts, assistant director at Montefiore Medical Group, stressed that one of the more difficult changes to overcome in addressing the opioid epidemic is that of social isolation of many people with serious health conditions. Even though well-established research shows that social isolation can be just as damaging for a person’s health as smoking, there is less evidence for solutions. Some health systems are even beginning to screen for it, but once identified, what therapies or “treatments” can be recommended: Would doctors be able to prescribe parties or social gatherings that are funded? He admitted he did not have the answer to this complex scenario, though there are likely many small-scale initiatives at the local and community levels to address loneliness and social isolation. Consideration of this problem in the context of family well-being as well as directing more funding and research toward this area could lead to helpful programs or activities. Continued high-level promotion of this issue, such as testimony to Congress calling for loneliness to be elevated to a public health priority (Special Committee on Aging, U.S. Senate, 2017) will hopefully spur additional investment and answers.
Social and Emotional Learning
As an avenue for new mental models, Santos mentioned the concept of social and emotional learning, which has become a stated emphasis of interest of the U.S. Department of Education’s Institute of Education Sciences (n.d.). As defined by the Collaborative for Academic, Social, and Emotional Learning, “[social and emotional learning] is how children and adults learn to understand and manage emotions, set goals, show empathy for others, establish positive relationships, and make responsible decisions.”4 Related to this, Santos said, is the mindset of meeting youth where they are, which may differ for each child. He suggested bringing the topic of social and emotional learning to the K–12 level. While it will not be possible to do for every class or every grade, he said that integrating these types of studies and making social and emotional learning more central for schools and
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curricula can be a good entry point to access many of these youth, and in doing so can eventually address other issues, such as health and wellness. There has been growing evidence of the benefits of building a stronger community within schools, especially for marginalized youth, whether through increased attendance rates, improved test scores, or additional achievements (Dee and Penner, 2016). Hawkins also noted the various states, with promotion from the Collaborative for Academic, Social, and Emotional Learning, require social and emotional learning to be taught in schools. He suggested that this type of interdisciplinary connection is important in the Forum’s work to promote children’s health.
Reducing Stigma
A participant asked the panelists about how to address the stigma against parenting programs. She sought suggestions on how to make parenting programs accessible and affordable to everyone without the stigma attached. Flores responded that, as the questioner noted and in his experience, many parents were ashamed to come to the relevant programs because they knew (as did the rest of the community) that the target audience was parents who were struggling or in a substance abuse rehabilitation program. Consequently, in Oklahoma, the focus of programs was shifted to be more “gamified” and now offers more culture classes and other fun things to attend without the fear of stigma. Slowly, he said, the staff are making inroads and connections and can build the trust needed to start conversations around sobriety, prevention, and the future of the children. But, he noted, to be successful, it is really important to let this process unfold slowly and not bombard parents with being sober at their first interaction. Sutherland added that in Montana the programs often use referrals from friends and family, so there is an element of privacy. They also try to orient the programs for everyone to enroll and not just specific groups of people.
Investing in People and Shifting Mindsets
Another mindset change in responding to the opioid crisis and its many consequences is shifting the thought to “investing in people” instead of punishing those who may be perpetrators but have often themselves also been harmed. This point was elaborated on by Slemp as he discussed his role in Wise County. “As a prosecutor, I have a duty to prosecute the law as it’s written, but the criminal justice system can’t just be black and white.” He added that criminal justice reform includes electing smart and progressive prosecutors to make a difference in people’s lives and understanding that each case is a person with a life and family. “We lose focus by getting hooked on mandatory minimums,” Slemp said, and what the crime was and
if it matches the punishment. Instead, he suggested, people need to look at what an individual is worth and can do, to invest in people.
Following further discussion, Slemp acknowledged that it is not easy to shift the mindset away from “do the crime, do the time,” especially for people in law enforcement. But what is really important prior to the implementation of any program is being committed to talking with various stakeholders and securing buy-in before moving forward. He said that he and his colleagues engaged law enforcement officers, judges, and community groups and presented examples of cases and how they might handle them through an alternative approach. The approach will still hold people accountable for their actions but, one hopes, can also work to propel them to an improved state.
Hawkins emphasized the importance of representation in getting children and teenagers to make the right choices and act in their own self-interest. He suggested that there has been a shared theme across all of the speakers and discussion comments—when people feel bonded to their community or their contacts (whether parents, coaches, or other mentors), they are more likely to listen to the recommendations being made. Though the “Just Say No” campaign by Nancy Reagan had the right intentions, Hawkins said, many children at the time did not know who she was or weren’t able to identify with her, so the message did not carry as much meaning as it could have if a different messenger was used.
