Wednesday, July 1, 2009

Wait, I'm not done yet....we have not yet spoken about the impact of Swine Flu on Mental Health reform

While the Physician Advocacy Fellowship may be over, there is still a lot of work to do.  Today, I was at a really interesting "debriefing" session hosted by my good friend Lauren Smith at the Department of Public Health discussing how the issues of school exclusion and school closing were handled in the recent (and current) influenza epidemic.  (Wait- what can this possibly have to do with children's mental health services, you ask?  Bear with me).  We have folks from the Commonwealth, mostly public health and education folks, people with various health departments and school nurses, and me (a simple country pediatrician), talking about what went well, and what could be improved.  DPH did a lot of stuff right in the recent outbreak;  they quickly wrote up clear and effective handouts, they disseminated them through the web, e-mail, phone-conferences and personal appearances to a wide variety people and they responded quickly to feedback.  Around the table, people applauded the speed with which the DPH people worked, and the collaborative spirit that fueled the effort.  Problems seemed to happen, however, when the message (sick kids should be home, schools should close only if certain criteria are met, people at high risk for complications need treatment) became too complicated and had to move outside of the public health system.  Complications happens when the message changed, which, early in the outbreak, was almost daily.  The CDC spent the first few weeks of April trying to figure out what was going on, and whether or not this virus was the "son of 1918" or not.  In that process, the message became fuzzy- in fact, it resembled our actual level of knowledge about this thing- but still, it created some confusion about exactly who was to be excluded for how long from which activities, who was to get antivirals and whether prophylaxis should play a role.  Handwashing was still the most important thing, but it took us a few weeks to get straight on the rest of the details.
LESSON 1:  Everyone needs to stay on message during times of change.  Don't change the message too often, even as you are working out the details.  For the CBHI, the implication is that it is really important for them to control the message of change, especially during the "ramp-up" time, to keep things from taking on a life of their own.
Now the other problem was the way in which the message was interpreted in the 351 (or so) semi-autonomous school districts in the Commonwealth, a largely local option that depended on the strength of local health departments, the ability of the school nurses to have a voice in the systems, the sophistication of the parents, the relationship with the local medical community, and, most importantly,  the leadership style of the superintendent.  Ideally, this would be a collaborative relationship in which the DPH would bring information and plans that the other sectors of civil society would embrace and implement.  Not so, in many cases.  Implementing this should have been a discussion, but it more often reflected and amplified the local power imbalances that drive action at the local level.  We heard stories of excellent collaboration and stories of serious conflict, as the needs of the schools for high MCAS scores were balanced against the need of the community for school closure.  According to the office of the legal counsel, the health authorities should have had precedence in this matter.  In practice, they often did not.  This is the place where many saw a need for improvement.
LESSON 2:  Implementing change requires buy-in from all of the parties, and will build on the relationships that were established in the past.  Or not.  For the CBHI, the implication is that forming the multidisciplinary teams, especially with doctors and educators, is going to be difficult.  We need to invest in building relationships.

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