9/30/2011
Systems
Of Care
Coffee Talk: What Does Coffee Have
to do with Expanding
Systems of Care
What Does Coffee Have
to do with Expanding
Systems of Care?
Beth A. Stroul, M.Ed.
Robert M. Friedman, Ph.D.
System of Care Community Training
July 19, 2011
TALK
Starbucks:
The Great Growth
Story of Our Time
“Revolutionized the
coffee industry”
“Rewrote the conventional
rules of business”
“Transformational power”
System of Care
Community Training
July 19, 2011
Beth A. Stroul, M.Ed.
Robert M. Friedman, Ph.D.
Albert Zachik, M.D.
Jane Walker, L.C.S.W.
David Jones, M.S.
1971
One store in Pike’s
Place Market, Seattle
Dream
To open second store
in Portland
2010
Opens 5 new stores
every day
16,858 stores in 55
countries
Disclaimer
• Not a commercial for Starbucks
• We don’t have stock
• We don’t know anyone in
management
• We’re not here to sell you on
Starbucks or to sell coffee
• They do a good job promoting
themselves – they don’t need us!
• And Starbucks isn’t perfect – has
had struggles adhering to their
values during expansion
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9/30/2011
Starbucks
Lessons for Expansion
• Lessons from Starbucks’ unique experience in
widespread adoption of an innovation
• Have worked to maintain quality while
continuing aggressive expansion
• Can it inform our work in expanding SOCs?
Goal
Widespread Adoption of SOC Approach
• Goal of the federal SOC
Program
Use time-limited
demonstration grants to
produce system changes that
are maintained after grants
and have a broader impact
by expanding the SOC
approach statewide, in
territories, and in tribes
“The Starbucks Experience: 5 Principles for Turning the Ordinary into the Extraordinary”
Joseph A. Michelli
“Onward – How Starbucks Fought for Its Life without Losing Its Soul”
Howard Schultz
New SOC Expansion Grant Program
• Purpose is to expand the SOC approach statewide
and throughout territories and tribes
• Grantees will develop a plan with concrete action
steps to create wide-ranging policy and program
transformation
• A researcher’s dream – Immediate opportunity to
apply finding in a new grant program.
• Requires use of system change strategies identified
as most effective through this study.
Expanding SOCs… Not Coffee!
Three Elements of Systems of Care
Identify Effective Expansion Strategies
• Previous sustainability study established critical role of
states, territories, and tribes in sustaining and
expanding SOCs, in partnership with communities
• Established need for a strategic planning and
implementation process for expanding the SOC
approach
• Led to current study to identify effective strategies for
expanding SOCs
Summary
of Study
Method
1. Developed conceptual
framework on strategies for SOC
expansion
2. Selected sample of 9 states with
significant progress in expanding
SOCs
3. Interviewed multiple state,
community and family
informants in each state focusing
on identifying effective
expansion strategies
4. Analyzed findings and currently
developing TA resources that
can inform current SOC
expansion efforts
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9/30/2011
States in Study Sample
Individuals Interviewed
Role of Interviewees
Arizona
New Jersey
Hawaii
Maine
North Carolina
Maryland
Oklahoma
Michigan
Rhode Island
9
Other State MH Agency Representatives
10
Other State Agency Representatives
3
Family Leaders
11
Local SOC and Children’s MH Leaders
16
Youth Leaders
1
University Representatives
32 Total Grants
# Interviewees
State Children’s MH Directors
TOTAL
2
52
4-7 per state
(13 Local, 5 Tribal & 14 States - 4 w/Statewide Focus)
Strategic
Framework:
Roadmap for
System Change
1. Implementing Policy,
Administrative,
Regulatory Changes
2. Developing or Expanding
Services and Supports,
Care Management, and
Individualized Approach
3. Creating or Improving
Financing Strategies
Implementing Policy and
Regulatory Changes
4. Providing Training, TA,
and Coaching
5. Generating Support and
an Advocacy Base
Strategies
Infusing & “Institutionalizing”
SOC Approach
• Creating an ongoing focal point of accountability at
state and local levels
• Developing and implementing strategic plans
• Strengthening interagency partnerships for
coordination and financing
• Enacting legislation
• Promulgating rules, regulations, standards
• Requiring in RFPs and contracts
• Incorporating in monitoring protocols
Findings
Most Effective Strategies
• Creating a locus of management and accountability for
SOCs at state and local levels
• Developing a strategic plan – formal or informal
• Requiring SOC approach in RFPs, contracts, regulations,
and standards
• Interagency coordination and financing
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How Does Starbucks Do It?
Requirements
“Green Apron Book puts into words the core “ways of
being” that you need in order to be successful at
Starbucks.”
• Guidelines/requirements in “Green Apron Book” in
each partner’s apron pocket
• Core philosophy and guiding principles are foundation
for everything
• “Be welcoming, genuine, considerate, knowledgeable,
involved”
How Does Starbucks Do It?
Cultivate Partnerships with Customers
• Comfy chairs, Wi Fi, music, friendly employees,
customized beverages, stay as long as you like
“Everything matters”
“Just say yes”
“Third Place – Home, Work, and Starbucks”
How Does Starbucks Do It?
Cultivate Partnerships with Key Stakeholders
“Starbucks management approach teaches that quality
relationships and enduring strategic partnerships are
essential to long-term survival and growth.”
Developing or Expanding
Services and Supports
• Partnerships with employees (called “partners”)
• Partnerships with stockholders, coffee farmers,
suppliers, community members, community
organizations, and others
Strategies
•
•
•
•
•
•
•
•
Creating a Broad Array of Effective,
Individualized, Coordinated Home
and Community-Based Services
and Supports
Creating or expanding array of services and supports
Creating or expanding care management
Creating or expanding individualized approach
Expanding family and youth involvement in services
Creating or expanding evidence-informed services
Creating or expanding provider network
Improving cultural/linguistic competence of services
Reducing disparities
Findings
Most Effective Strategies
• Creating a broad array of services and supports – adding
nontraditional home and community-based services and
supports
• Implementing individualized, “wraparound” approach –
operationalizes SOC approach at service level
• Creating or expanding care management and care
management entities
• Expanding family and youth involvement in services
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How Does Starbucks Do It?
Findings
Underutilized Strategy
• Improving cultural/linguistic competence of services
• Expanding the use of evidence-informed and
promising practices
Broad Array of Services
• Started with coffee and tea – Now diverse and everexpanding menu
• Added pastries, sandwiches, paninis, breakfast
sandwiches, salads, fruit, coffee beans, instant
coffee, smoothies, kids drinks, bottled drinks, instant
coffee, frappuccinos, (even low fat versions)
• Coffee makers, grinders, travel mugs, mugs from
every city
• Music mixes, books – what’s next?
• “Espresso dating” in collaboration with Yahoo
personals?
How Does Starbucks Do It?
How Does Starbucks Do It?
Individualized Approach, Care Management
“Customers must be able to customize their
beverage order, with the hand-crafted assistance of
their barista [coffee preparer].”
• Satisfy each customer’s unique needs and
expectations
“Venti, sugar free, nonfat, vanilla soy, double shot,
decaf, no foam, extra hot, Peppermint White
Chocolate mocha, with light whip and extra syrup”
Cultural and Linguistic Competence
“Starbucks has gone into diverse communities with
commitment to do the right thing and provide people with
quality options.”
• Proactively understand the unique character, culture, and
needs of a neighborhood and adapt to fit the culture
• Some communities have unique requirements– kosher
products, menu in Spanish, staff with sign language skills
• Reaching out and volunteering or fund-raising in local
programs and causes
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Strategies
Developing or Improving
Financing Strategies
Creating Long-Term Financing
Mechanisms for SOC
Infrastructure, Services, and
Supports
• Increasing ability to use Medicaid financing
• Obtaining new or increased state MH funds
• Obtaining new or increased funds from other childserving systems
• Blending or braiding funds across systems
• Redeploying funds
• Obtaining new or increased local funds
• Increasing use of other federal entitlements
• Obtaining federal grants
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Findings
Findings
Most Effective Strategies
Underutilized or
Emerging Strategies
• Increasing ability to obtain Medicaid financing –
waivers, adding new services, changing existing
definitions, using rehab option, etc.
• Using federal grants (primarily SOC grants)
strategically
• Redeploying funds from higher cost to lower cost
services
• Using federal block grant funds strategically
How Does Starbucks Do It?
Profitability is not a dirty word
“Even the Starbucks mission statement acknowledges
that profitability is essential to future success.”
“Profitability increases not only the breadth of the
Starbucks market, but also the scope of its positive social
influence and its capacity to provide quality benefits for
partners.”
Providing Training, TA,
and Coaching
• Sound, sustainable financing strategies are essential for
SOCs to expand and provide quality services to children
and families
Strategies
Preparing Skilled Workforce to
Provide Effective Services and
Supports in SOCs
• Providing training and TA on SOC philosophy and
approach
• Providing training, TA, and coaching on effective
services
Findings
Most Effective Strategies
• Providing training, TA, and coaching on SOC approach
• Creating the capacity for ongoing training and TA on SOC
approach
• Creating the capacity for ongoing training and TA
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9/30/2011
How Does Starbucks Do It?
Providing Training
“Training is usually one of the first items to be cut in
tough financial times, but Starbucks knows that
‘knowledge is power’ and continues to invest a lot in
training as critical for future growth.”
• Extensive training for partners at all levels in
product knowledge, guiding principles, personal
empowerment, customer experience and support
• Certification of partners as “coffee masters” after
training and proficiency tests
Generating Support and
an Advocacy Base
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Strategies
Generating Support from Key
Stakeholders and High-Level
Decision Makers
• Establishing strong family and youth organizations
• Cultivating partnerships with key stakeholders
(e.g., provider agencies, MCOs)
• Generating support among high-level administrators and
policy makers
• Using data on outcomes and cost avoidance to “make the
case” for expanding SOCs
• Creating an advocacy base through social marketing
• Cultivating leaders
Findings
Underutilized or Emerging Strategies
• Using data on cost avoidance
• Creating an advocacy base through social marketing
(Social marketing involved in all of these strategies)
Findings
Most Effective Strategies
• Establishing a strong family organization to
advocate, support, and be involved in expanding
SOCs
• Generating policy-level support among high-level
administrators and decision makers at the state level
(with education, data, social marketing)
• Using outcome data to “make the case” for
expansion
How Does Starbucks Do It?
Generate Support
“When the concerns of critics are allayed, those critics can
often become your most ardent supporters.”
• “Other-oriented approach” to seek support from
decision makers – shareholders, managers, co-workers,
customers, vendors, communities, etc.
• Tackle important issues – global and local such as
environment, literacy, health for farm workers
• Approach complex and controversial issues with
willingness to listen and respond to concerns and ideas
raised by stakeholders and adversaries
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9/30/2011
How Does Starbucks Do It?
Use Data
“Resistance is often the direct result of lack of
information about the company or its products or
service.”
• Provided data showing that independent coffee
shops retain 51% market share and new
competition can actually infuse energy into
existing businesses rather than put them out of
business
• Evaluation mailer at each store invites feedback
from customers that is analyzed and used for CQI
and to guide expansion
Roles of SOC Communities
in Expansion Efforts
Findings
Most Effective Strategies
• Testing, piloting, exploring
the feasibility of approaches
• Providing training and TA to
other communities
• Providing data on outcomes
to “make the case”
• Contributing to the
development of statewide
family organizations
Most
Significant
Barriers
Importance of
leveraging SOC grants to
expand impact beyond
individual communities,
using SOC grants as a
basis for making major
system changes
•
Fiscal crises and budget
cuts
•
Changes in
administration that
resulted in policy
changes
•
Insufficient buy-in and
financing from other
child-serving systems
•
Lack of a children’s MH
workforce trained in
SOC approach
Barriers
How Does Starbucks Do It?
Address Barriers
• “Emerging Issues Council” that meets to anticipate
potential problem areas and look for solutions
• Engages in conversations with those likely to create
barriers and search for common ground, rather than
ignoring or resisting them
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Strong Value Base
• Importance of foundation in SOC
philosophy that is broadly
accepted
• Work often began 25+ years ago
with CASSP
Guidelines for
SOC Expansion
“Starbucks markets to its employees how
important the guiding principles are for the
environments it hopes to create and the
legendary services it hopes to provide.”
Plan with Multiple Strategies
Opportunism and Adaptability
• System change may appear more
planful than reality – Combination
of planned strategies and
leveraging opportunities that
emerge
• Expansion occurs within different
contexts and with different
pathways
• Need a plan (whether called
“strategic plan” or not) –
expansion doesn’t just happen
• No results from just a few
strategies – synergistic impact of
multiple strategies over time
“Starbucks is about being innovative, being
entrepreneurial, being positioned to take advantage of
opportunities that first and foremost add value to the
Starbucks experience.”
• States making progress are skilled
in adapting to political, economic,
and other contextual changes
“While Starbucks leaders spend most of their time looking at
big-picture strategic opportunities, they do not overlook the
systems and strategies necessary to ensure the quality of
every aspect of the company’s products, services, and
processes.”
Maintain Quality
“When undisciplined growth became a
strategy for Starbucks, we lost our way.“
“Perhaps the most vital thing that came out
of the [expansion] has been the confidence
we gained knowing that we could preserve
our values despite the hardship we
faced. Holding fast to those values steadied
us throughout the tumultuous journey.“
• Adhere to SOC values
• Monitor and maintain quality with
growth
“Starbucks is sensitive to fears about the company’s
expansion and adjusts to the needs and customs of new
environments.”
Progress
“Starbucks is still in early stages of growth,
second inning of nine inning game, the
beginning chapters of long book”
• We’re in first inning of expanding SOCs
• Most states in sample are continuing
progress even with fiscal crises and
budget cuts – seen as a barrier and an
opportunity
• No state is all the way there!
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Magic Formula
Progress
• Planning and resources through new
SAMHSA expansion program can be the
“tipping point” to progress
• Links to Block Grant, Medicaid, other
system initiatives are essential to
continue progress
• Importance of health reform – essential
to link with implementation of the
Affordable Care Act
• There is no magic formula!
• Starbucks not perfect, but has experience
of “culture-changing growth”
• SOC approach is not perfect, but we seek
the same culture-changing growth
“Beware of naysayers who say ‘it can’t be
done’ and focus on how to make it work.”
Magic Formula
“It’s not a magic formula for success…. Well,
maybe it is magic, because there’s
something magical about founding a
business that aspires to enrich the human
spirit.”
• And there’s something magical about the
SOC approach that aspires to improve the
lives of children with mental health
challenges and their families
Maryland:
Key
Features
A Strategic
Approach
• 5.7 million people, 24 jurisdictions
• History of overreliance on residential and
out-of-state treatment
• Have undertaken a strategic approach to
statewide SOC development, with
approaches in each core strategy area
• Small strategic steps over many years
• Leveraging of federal grants and other
opportunities to support implementation
• Expansion efforts have survived budget
cuts and changes in administration
• Interagency Children’s Cabinet structure at
state and local levels
• Interagency Strategic Plan and Blueprint
for Children’s Mental Health with strong
SOC vision and action steps
• Strong MD Coalition for Children’s Mental
Health
• Care Management Entities (CMEs)
statewide
• Wraparound approach statewide
• Medicaid and interagency financing
• Innovations Institute for workforce
development
• Strong state-local partnerships
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Utilize a
Clear,
Evolving
Maryland’s
Approach
for
Expanding
SOCs?
• Utilize a clear, evolving action plan
• Ensure committed cross-agency leadership
• Ground the work in a consistent value
system
• Leverage multiple financing streams
• Test approaches and build on successes
and lessons learned
• Support the workforce
• Ensure strong family voice and advocacy
• Ensure ongoing local voice and choice
Ensure
Committed
CrossAgency
Leadership
State Level Leadership and
Accountability
• Children’s Cabinet at Governor’s
Level
• Office of Child and Adolescent
Services within state mental
health authority
Local Level Leadership and
Accountability
• Local Management Boards
• Local Mental Health Authorities
• Regional CMEs for high-need
Children
Grounding
in a
Consistent
Value
System
Incorporate SOC values/approach in
strategic plans, Medicaid and mental
health regulations, contracts with CMEs
and providers
• Partner with families and youth at
all levels in the system
– Contract with family
organization for policy-level
involvement
– Fund family navigators and
peer-to-peer support
– Families and youth drive child
and family teams in
wraparound approach
Action Plan
• Blueprint Children’s Mental Health (2003,
2009 Update)
• Child and Family Services Interagency
Strategic Plan (2008)
– emphasized importance of family
voice, CMEs, evidence-based
practices, interagency communication,
and effective financing
• Children’s Health Insurance Program
Reauthorization Act (CHIPRA) Quality
Demonstration Grant
– opportunity for the next iterations in
SOC development and sustainability
Grounding in
a Consistent
Value System
• Focus on shifting services and supports
to individualized, coordinated,
culturally and linguistically competent,
and home- and community-based
– Expand array to include in-home,
respite, family peer support, psych
rehab for children, etc.
– Implement CMEs (4 pilots to
statewide)
– Implement wraparound approach
to engage, plan, deliver services
– Recruit and train culturally diverse
providers and embed cultural
competence in care planning
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Leverage
Multiple
Financing
Streams
• Obtain and leverage federal
grants to initiate system changes
and pilot approaches
– SOC grants, Transformation grant,
Statewide Family Network grants,
etc.
• Increase use of Medicaid for
ongoing financing
Build On
Successes
(and lessons learned
from what hasn’t
worked)
– Broaden array of covered services in
state Medicaid plan
– Multiple options and waivers
– PRTF Demonstration waiver and
CHIPRA Grant
– Generate match with funds across
child-serving systems
Develop
the
Workforce
• Innovations Institute at Univ. of Maryland
—training, TA, coaching, wraparound
practitioner certification, evidence-based
practice intermediate purveyor
• Maryland Virtual Workforce Training
Center
• Core Elements Training
• Annual Statewide SOC Training Institutes
• Children’s Mental Health Institute –
university partnership promoting
evidence-based practices
• Early Childhood Mental Health Certificate
Program
Establish a
Strong
Family
Organization
• Use local SOC grants and other
local SOCs to inform evolving
statewide expansion
• Grants build on each other,
required to tie in with state efforts
• Used grants as pilots for CMEs,
wraparound with child and family
team approach
• Transformation Grant enabled
support of SOC initiatives across
administrations
• Blueprint, Interagency Strategic
Plan, and the Report on Youth with
Co-Occurring Disorders all align and
build on previous initiatives
• MD Coalition of Families for Children’s MH
(established in 1999), supported with
Block Grant, Statewide Family Network
Grant, SOC Grants, PRTF Waiver, Children’s
Cabinet Interagency Funds
– Has a “seat at the table” as policy is
formulated
– Critical to survive changes in
administration
– Provides SOC training in partnership
with Innovations Institute
– Holds Family Leadership Institutes
– Leads annual social marketing efforts
“Children’s Mental Health Matters!”
• Early Childhood Consultation Program
Ensure
Ongoing
Local Voice
and Choice
• Collaboration among MD Coalition
of Families, State Dept. of Health
and Mental Hygiene, Local Mental
Health Authorities, and Local
Management Boards
• Incorporate local input and
expertise from communities
• Utilize “Community Champions”
who are experienced and
committed to implementing the
SOC approach
• Factor in politics- “All Politics are
Local”
And Maryland has…
Been Strategic —
• Applied for available grants, used as pilots
• Used strategic plans, legislation and regulations to
“institutionalize” SOC approach and keep moving
forward across administrations
• Grounded pilots and initiatives in research and best
practices
• Ensured that evaluations were connected to each
initiative
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And Maryland has…
And Maryland has…
Made Connections —
• Demonstrated how various initiatives are linked and
produce better outcomes for children and families
• Worked with and learned from different states
• Established partnerships with universities and family
organizations
• Cross-walked all national evaluations for different
grants to create one minimum data set that is
collected by CMEs
Leveraged –
• Used local, state, and federal grant funds to pilot
approaches, and Medicaid to sustain them
• Accessed Medicaid funds (waiver, state plan), SAMHSA,
and Children’s Bureau funds
And Maryland has…
And Maryland Looks to the Future….
Experienced Growing Pains
• Sustaining the family organization
– Evolving from grant funded to Medicaid fee-forservice
• Evolution of Youth MOVE – Stops and starts
• Balancing local control in a state driven system
• Adhering to
SOC values
• Getting our
message
across
• Bringing
together key
partners in
your state to
make it
happen
• all
Keeps an eye on the past while looking forward to
the next opportunity
• Health care reform is an opportunity to continue
to solidify the role of SOCs in our systems and
services
• CMEs as possible health homes
• Exploring the use of the 1915(i) state plan
amendment for sustaining the 1915(c) PRTF
Demonstration Grant
We got coffee……
• Building on
what we know
• Capitalizing on
new grant
opportunity
Evolved –
• No strategic plan or initiative is created from scratch
• Regulations and statutes are implemented or revised to
be consistent with current best practices and initiatives
The
Challenge
Ahead
And we will have systems of care…
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Check Under
Your Chair!
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