Wednesday, March 26, 2008

Collaboration: The friend of Rosie D.

The meat of the matter- how do we collaborate? Most of the children in the class of SED were buffeted about the system like the kid in "Officer Krupke" from "West Side Story".  How do we break through the silos? How do we make it all come together?  

(1) What structure(s) would best support collaborative practice between public agencies and among private providers? What are the advantages and disadvantages of addressing coordination issues among public agencies and private provider agencies in the same forum? Should there be separate settings for these discussions? How can MassHealth best ensure integration of all aspects of delivery of care and mutual accountability for outcomes?
This is a tricky question, and key to the outcomes of this remedy.  The structure that will best support collaborative practice is the one that best allows integration of the needs and strengths of the family with abilities and resources of the agencies involved.  The ICC will need to work with the family in the process of developing the service plan to identify the structure that will support the family best,  and assure that the agencies and providers are able to utilize that format.  At some level, it is important to put faces to words, but much of the work can likely be accomplished through virtual formats.  MassHealth needs to ensure that there is regular communication within the treatment team, to avoid a crisis-focused approach.
MassHealth should provide for a variety of formats to accomodate the different types of teams with which we are dealing:
1)  Face-to-face:  Catalog and contact information for facilities willing to host multidisciplinary team meetings, travel reimbursement, access to on-line scheduling service.
2)  Phone meeting:  Reimbursement to support time and cost of conference calls.
3)  Virtual meetings:  Secure "chat rooms" and "bulletin boards" for sharing confidential informantion.
4)  Shared single care plan:  On-line care plan accessible to all parties (so that each can see what the other is doing).
It seems likely that an initial "face-to-face" meeting followed by routine conference calls will likely be the preferred format for interaction, but, ultimately, the adequacy of the interaction should be judged by the needs of the family and the outcomes of care.

(2) What are your suggestions for ensuring collaborative practice among different individual providers or provider agencies serving the same child/family?
The current system of reimbursement does not encourage collaborative behavior- the various components of the system are rewarded for each piece of work done, not for work avoided through collaboration. Reimbursement needs to reflect the quality of the interaction as well as the quantity of the services provided. I would suggest considering the families assessment of the degree of collaboration as a multiplier to reward collaborative behavior.

(3) What are your suggestions for SOC Committee membership and meeting format to balance the value of having family and youth represented on the Committee with the need to protect the privacy of children and families involved in ICC?
In a truly family-centered paradigm, it is difficult to imagine “one size fitting all”; the SOC membership needs to reflect the array of services and service providers that are working with a given family. This is a deeply personal negations between the intensive care coordinator and the family. Some portions are non-negotiable (ie. DSS must be involved with clients engaged in the system, whether the family wants it or not) and it will be difficult when the family has had conflict with one of the agencies essential to service delivery (ie if the family has long-standing disputes with the Special Education Department, they may not want to invite them to be on the team even though they are essential to the process). I suspect that the most difficult cases will be those in which custody is in dispute. The care coordinator needs to be given discretion and training to negotiate and sometime mandate who will be on the team.

(4) What are the advantages and disadvantages of combining discussions of policy and general coordination with discussions of specific service coordination problems, which would require disclosing personal information? Should there be separate settings for these discussions?
Generally, these discussions take place at different levels within agencies. While it is important for fieldwork to inform policy, field workers are usually not in a position to set policy, except in some of the smaller agencies. Still, in order to relate policy to reality, it is important to have discussions in which those that set policy hear how the policy plays out in specific cases. In medical culture, this occurs at the “M and M” conference, in which the details of a specific case are discussed (with identifiers removcd) in a secure and non-discoverable environment (papers burned afterwards). This may be a model that would be useful to this process of multi-agency collaboration, and may require legislative protection similar to that afforded medical staff in hospitals.

(5) What suggestions do you have or lessons have you learned for facilitating partnerships with school districts?

In general, all agencies have a specific mission, and they will collaborate with “outsiders” based on the abilitiy of the outsider to help them to achieve that mission. With schools, it is about improving educational outcome, so as an “outsider”, I have had to think about how my expertise can help a school system accomplish its mission (and how they can help me to accomplish mine). This is a nuanced take on the prime question “How can I help this child”. Several other hints:
1) Show up. Schools respond to people to respond to them through team meetings.
2) Match objectives: Completing homework is a great measurable behavioral objective that meets my needs as a prescriber and their needs as educators.
3) Share information: A five minute phone discussion can cut through weeks of written messages.
4) Understand their schedule: Schools are open on school days and are generally closed by 3 PM. Call in the morning.

(6) What suggestions do you have or lessons have you learned for facilitating partnerships with juvenile courts? Probation?
Actually, substitute courts and probabtion for schools in the above paragraph, and you have a reasonable set of advice.

(7) What suggestions do you have or lessons have you learned for facilitating partnerships with broader system partners?

(8) Do you have any other comments or suggestions on these subjects?
All of this collaboration takes time, and we need to reimburse individuals and agencies for taking the time to collaborate.

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