AMCHP posed the following question to CSHCN directors from three different states:
As your CYSHCN department transitions from a direct service to community-based system, what have you done, are you currently doing, and plan to do to prepare your workforce for the change in their roles?
Dr. Harper Randall
Medical Director of the Utah CSHCN Bureau
The overriding focus at the CSHCN Bureau in Utah is to preserve programs which offer early diagnosis and referral and programs that provide access to diagnostic services in rural areas. Given increasing budget constraints, local political directives and lack of services available in rural communities, our bureau has decided to approach transitioning in pieces.
What have you done:
We have restructured our Salt Lake-based School Age Program from a direct care model to a care coordination and education model. This program previously offered a multi-specialty diagnostic team that provided evaluations and developed care plans which included the families, schools and other health professionals. We now have a part-time child psychologist and developmental pediatrician who provide phone consultations to medical homes (MH) about difficult cases and resource identification and care coordination to families of school age children and youth. These efforts are being supported by a parent friendly website.
What are you currently doing:
We have developed a downloadable referral form for local MH that surrounds our eight satellite clinics. The goal is to improve communication between CSHCN and MHs, between MHs and their patients and empower the MHs to order the tests/imaging themselves. To do this we are improving communication between the clinics and MHs, encouraging MHs to include information such as previous history, work-up and questions remaining on the referral form, and providing information back to the MH within 48 hours.
We are beginning the process of a strategic plan, focusing on our 8 CSHCN satellite clinics and the surrounding communities’ readiness to support aspects of the CSHCN clinics within these communities. We have identified and met with the task force and have rewritten our vision and mission statement. We are in the process of developing of matrix for community readiness.
Plan to prepare:
We will be emphasizing the 10 Essential Public Health Services, the 6 MCH Core Outcomes and the MCH pyramid in future discussions with our work force to reinforce that we can’t fix a broken medical system nor is it our role. We should be using our limited funds to serve all CYSHCN in Utah, not a few. We will be offering copies of Managing Transitions by William Bridges. This book is essential reading for those going through the tough process of transition in the work place.
Director of the CSHCN Program in Maine
What have you done?
When the Maine CYSCHN Department first embarked on this journey we conducted a self assessment to gauge each employee’s preparedness to move to a community-based system of care. The responses (5) revealed that folks identified themselves with their direct service responsibilities and they had a lot of anxieties and frustrations about the upcoming transition. These fears where justified and to many it felt like we were embarking on trip with no itinerary. I personally love to plan trips without itineraries and, as Robert Frost said, “take the road less traveled.” While I was confident that these unexplored roads are filled with great opportunities, I also realized that if I were going to take people with me, I needed to plan the transition thoughtfully and fully engage others in the development of this new program.
First, I prepared my staff for a major shift by rationalizing why we needed to make this change. My budgetary explanations were just not enough to get all staff on board, so I took a different approach and decided to look at data (something my direct service staff had never had the opportunity to see). Using SLAITS data, I shared with staff that by using a direct services model we were only able to provide services to less than 5% of children with special health care needs in Maine. The data also indicated that many families wanted and needed greater access to community-based services. Upon seeing these numbers, lights bulbs finally started to go off and my team began to say “we could provide care coordination to these folks.”
What are you currently doing?
Right up front I’d like to say it is not an easy decision to move from a direct service program to a community based program. Not only do you have to consider how this transition affects your staff but how it will affect families, providers and others you have partnered with over the past 20 or so years.
In order for us to prepare families and staff for this transition, we developed a system that allowed staff to take control of their own destiny while preparing for the shift. Staff ranked families based on need (1, 2, or 3) by looking at costs of medications, provider, income, number of family members and type of insurance. We found a large number of families identified as 1’s had commercial insurance, 1 or 2 medications, and 1 or 2 providers they saw on an annual basis. We developed talking points and scripted messages, and then staff contacted each family about the transition of our department and why we would not be re-enrolling their child in the program. Most, if not all, families were grateful for the years that we had been able to assist them. We encouraged families to contact us if they needed assistance searching out other resources if needed.
The 2’s and 3’s are more problematic. These families may or may not have insurance, have multiple medications and providers, and financial assistance from the CSHN Program for those items that are not covered by insurance. The staff and I have decided to take more time and review each of these families as a team, discuss alternative financial resources (Medicaid, etc.) and then call families to discuss priorities and solutions. To date we have only moved a few of the 2’s and 3’s off of our roles, but we are willing to move slowly to ensure that these families are covered. The staff continues to recognize their new role in helping families navigate the complex system of services in Maine. A changing role, maybe, but one that they have readily accepted!
What do you plan to do?
Although not fully developed, I plan to encourage staff to reassess their dreams and expectations about this move, revisit any persistent or lingering fears, evaluate their strengths and identify areas they feel they need to develop knowledge. Once completed, the staff and I will develop a training that addresses their changing roles.
If I learned anything in this process it is the importance of communication. Identify problems quickly and develop solutions by involving the whole team. Keep minutes of meetings and keep moving forward, even if it is baby steps. Remember, that it is okay to grieve about the past but it’s more important to celebrate accomplishments.
Chief of Missouri’s CSHCN Program
Change is a constant for state employees. Typically, state merit system rules run counter to building workforce capacity to quickly adapt to changing roles and duties. My goal is to help staff members view interacting with change as a positive and as an opportunity. Achieving this requires all of the skills of good leadership.
In Missouri we have reviewed and modified organizational structure with the stated aim of helping staff adapt to changing responsibilities. Structure is a powerful representation of how the organization should operate. Lines of authority and demonstrated areas of responsibility are designed to model flexibility in operations and in individual responsibility. Due to role rigidity that is inherent in the state merit system, it has also been important that leadership clearly define new ways for staff to address challenges and tasks. I have endeavored to teach teamwork in a functional manner. Time-limited work groups are often used to find solutions to particular issues, either a specific problem or an identified area that needs refinement. Thematically, each work group is helping to fulfill the Bureau Mission: serving Missourians with special health care needs. In addition, these teams also demonstrate a dedication to engage all staff members in finding creative and innovative solutions to these challenges. Since staff members have a stake in shaping the new ways in which the organization continues to serve Missourians with special health care needs, they become less concerned about previous ways of doing business and more focused on the new operational methods. Ultimately, Bureau staff members have always been dedicated to serving Missourians. That dedication forms a basis for operating in new ways.