The paradigm shift
The issue at hand was a theoretical paradigm shift, changing the narrative from what’s wrong with you, to what happened to you? It was necessary because the science behind the effects of trauma in childhood was clear – what happens to us in our first 18 years of life positively or negatively affects the trajectory of our lives. The Adverse Childhood Experiences is a pivotal longitudinal study linking childhood trauma to negative health outcomes in adulthood – such as cancer, heart disease, COPD, diabetes, mental health disorders, and addictions. If you haven’t already, take a moment to review the Alberta Family Wellness Initiative resources and consider the impact. It’s powerful.
The sector
The entire vulnerable serving sector needed to shift. It meant looking upstream to the root causes of poverty and trauma. We advocated for policy changes at various levels of government, along with identifying formal and informal community partners to create a connected network of information sharing and referrals. The changes at all levels were costly, and impossible without government, corporate and individual donors. And, of course, all changes were happening with a focus on creating better outcomes for those suffering from the effects of poverty and trauma. Needless to say, our external stakeholders were extensive and diverse. This work is ongoing, and Alberta is at the forefront of innovation, making system changes to accommodate innovation. The article by Conway et al. (2017) describes the need for both design and systems thinking to find innovative ways to solve our wicked problems, such as the intergenerational transition of trauma and poverty (p.1). Calgary is championing design and data-driven thinking, evidenced by its participation in projects, such of the Data for Good – National Datathon, working to transform mental health care through data-driven insight.
The organization
Within our organization, we moved from one-off ‘band aide’ short-term solutions to a holistic intake assessment and care planning process that included integrating health, housing, education, community and family connections, spirituality, and basic needs. We moved from eleven different access points into programs and services to two – health and non-health (everything else). We shifted from a service and support focus to a person-centered approach in partnership with clients. This transition took both systems and design thinking.
Our executive director was a value driven leader that could deliver a compelling vision. The entire organization was able to ‘buy in’ and there was a clear business case for it. Getting to the root problem does save lives and reduce costs. The organization took time to prepare for the change in many ways, and provided opportunities for staff training, collaboration and input – this list is not exhaustive:
- Created new roles and a new organizational chart
- developed a detailed strategic plan
- identified agents of change early
- hired consultants for change management, and project management
- conducted town halls and focus groups with staff
- surveyed clients – but maybe not enough
- ADKAR training to all staff
- scheduled consistent all staff meetings
- scheduled consistent director and management team meetings
- started a community of practice
- hosted cross agency coffee and chat times on Fridays
- creted an integrated care prototyping committee
- created a community of practice
- use of Gantt charts and other project planning tools
- Mandatory completion of Brain Story Certification, Trauma Informed Care, and MANDT training in support of the science behind integrated care.
- Investments in technology development for care planning and data capture
With the benefit of hindsight
Despite considerable preplanning, and well-intentioned efforts to prepare and support staff through the transition to integrated client care, many barriers slowed progress. Two that created considerable challenges were: power dynamics between siloed departments, and the physical structure of our building.
First, I wish Antwi and Kale’s article (2014), Change Management in Healthcare Literature Review, was required reading in preparation for the implementation. It highlights many of the challenges that came up along the change journey. Their notion of power dynamics and the hierarchy of influence in the organization (Antwi & Kale, 2014, p. 18) was our biggest hurdle. We started by integrating our housing and education services, and the teams were willing to collaborate and develop new systems to support the process of intake and care coordination. Although the Health Clinic was supportive of the vision, they were largely unwilling to compromise on an integrated intake. This left us with 2 access points to services – health, and everything outside of health. Which then led to the never ending debate about what constitutes health related information. It illustrated how much power and influence this department had over the organization. In hindsight it could have been more productive to work with the most resistant department first. The second barrier to progress was the physical structure of the building.
We spent 6 months piloting various points of entry into the building that could accommodate a single point of intake. The space we ended up using was not ideal. It didn’t provide enough privacy for clients and posed security risks to staff. The result was that the strategic plan was extended by two years to support the construction of a new entrance and intake space to support the shift to integrated care.
The sector and its organizations are all still evolving over time to catch up with what we now know through science and data. I learned that even with careful planning the knowledge available at the time, along with many mistakes and missteps along the way, change takes time, and you really don’t know how things are going to unfold until you try. The burden of stress is carried by the individuals who believe in a vision and commit to bringing it to life. A big shout out to all the changemakers!
References:
Alberta Family Wellness Initiative. (n.d.). ACES. https://www.albertafamilywellness.org/what-we-know/aces/
Antwi, M., & Kale, M. (2014). Change Management in Healthcare: Literature Review, (January), 1–35. https://smith.queensu.ca/centres/monieson/knowledge_articles/files/Change%20Management%20in%20Healthcare%20-%20Lit%20Review%20-%20AP%20FINAL.pdf
Convergence. (n.d.). The Convergence – Data for Good National Datathon. https://www.convergementalhealth.org/event/the-converge—data-for-good-national-datathon-a-movement-for-mental-health-data-innovation
Conway, R., Masters, J., & Thorold, J., (2017). From design thinking to systems change: How to invest in innovation for social impact. Royal Society of Arts, Action and Research Centre. https://andiroberts.com/wp-content/uploads/2020/04/rsa_from-design-thinking-to-system-change-report.pdf