# Presentation: 162928

## What Works: Systems Change

**Carol Wilkins**
**Director of Intergovernmental Policy**
**Corporation for Supportive Housing**

**Notes:**
The Bureau of SA Services, DTA and DMH have been offering targeted services to homeless individuals and families for many years.  This presentation is an overview of the services provided by the BSAS, including collaborations with other EOHHS agencies and other partners.

## The Corporation for Supportive Housinga national non-profit intermediary organization

***CSH supports the expansion of permanent housing ***
***opportunities linked to comprehensive services for persons ***
***who face persistent  mental health, substance use, and other ***
***chronic challenges, and are at risk of homelessness, so that ***
***they are able to live with stability, autonomy, and dignity, and ***
***reach for their full potential.  We work through collaborations ***
***with private, nonprofit, and government partners, and strive to ***
***address the needs of, and hold ourselves accountable to, the ***
***tenants of supportive housing*****.**
**www.csh.org**

**Notes:**
Introduce myself & CSH:  
first became involved in efforts to end homelessness in late 1980’s when SF Mayor Agnos introduced Beyond Shelter plan
as Finance Director for city & county I saw impacts of the “crisis” of homelessness, untreated mental illness and substance abuse (especially crack epidemic) – impact not only streets and demand for shelter but also jail overcrowding, rising foster care caseloads.  Board Finance Committee director would not approve plans for building a new jail until we examined “client overlap” 
For past 8 years at CSH, working full time on systems change to integrate services needed by people who would otherwise experience long term homelessness and/or impose significant costs for inappropriate use of health services, and integrate the systems that deliver and finance housing, health care and other services.  Learned from folks like you that it takes more than funding and changing the rules – also changing people, habits, and systems.  Requires time, creativity, passion and persistence, as well as some patience and understanding.

## Why An Integrated Service System?

**People who are chronically homeless have multiple needs – for health care, treatment, housing, income supports, skills training, and jobs – that can not be addressed by a single service system**
**People who are chronically homeless experience many obstacles to accessing housing and services  **
**Long term homelessness imposes substantial costs in multiple systems – there are opportunities to achieve and re-invest savings**

**Notes:**
Why Systems Change (you saw this as pre-Academy meeting but it’s helpful to remind ourselves):
Why is it needed?
Why is it worth the effort?
You have heard 
From Fred Osher that evidence based practice for this population requires integrated services and assertive engagement / continuity of care and linking services with housing instead of fragmentation and barriers
from Dennis Culhane about NY – and you may have begun to quantify in your own state – some of the costs associated with chronic homelessness (who’s paying for it now?) – e.g. frequent hospital utilization, jail overcrowding, psych emergency care, public disorder

## Goal of a Comprehensive and Integrated Service System

**People who are chronically homeless can enter any service “door”, be assessed, and obtain access to the full complement of services and supports that they want and need**
**Services and supports can adjust to meet changing needs while people achieve and maintain housing stability**

**Notes:**
Your state teams have established a vision statement that probably looks something like this
Maine (proposal): each individual ... has barrier-free access to a comprehensive array of coordinated housing and supportive service options that maximize self-sufficiency and quality of life

## What is a System?

**The way in which . . .**
**Power**
**Money**
**Ideas and values**
**Technology or know-how (methods & skills)**
**Day-to-day routine (habits)**
**. . . are linked to achieve a mission or goal**

**Notes:**
The “system” is the set of relationships that link these 5 elements with each other and with the goals that they are meant to serve.

## How Systems Change Occurs  Someone recognizes a better way of doing things, leading to changes in:

**Power: duties and authority are re-arranged and designated positions are responsible for new activities**
**Money is routinely or reliably allocated in new ways**
**Ideas and values: “success” is defined differently, using different data, standards, and values that are widely shared**
**Methods: Skilled practitioners at most levels have experience using new approaches**
**Habits: participants in the system interact with each other differently as part of their jobs**

**Notes:**
These are “the five signs” or key elements / indicators of systems change.
Achieving real and lasting systems change is different from (more than) making the system do something innovative – it’s about new patterns of doing things in a new way on a consistent basis so they become habit –an accepted part of the way people and organizations do their jobs 
People and systems regularly do the new thing – not just in response to a special initiative, or because particularly skilled or committed individuals happen to care about it – and others can rely on the system to operate in a changed way

## Getting to a Changed System

**Usually a system hasn’t truly changed until:**
**Most or all of the five signs are visible, and**
**The difference has endured for years, not months**

## Effective Systems Change

**Requires***** persistent***** pressure on *****most***** or *****all***** of the key elements over a *****sustained***** period of time**
**To get there, often begins with:**
**Persuasive short-term accomplishments**
**Producing a new product or service by extraordinary means, just to show it can be done and is worth replicating**

## Impetus for Systems Change

**When a Governor orders a major policy change**
**When the Federal government allocates money in a new way**
**When public philosophy or ideology shifts fundamentally**
**When a court mandates a new government obligation**
**When technology or know-how changes**
**The surrounding *****system***** may then change *****if***** the difference is profound and long-lasting**

**Notes:**
Discuss examples:
Governor Weiker in CT ordered people from state agencies to establish inter-disciplinary planning bodies, collaborate with CSH, and used state authority to resolve siting disputes.  This approach can have significant impact but need to anticipate leadership changes and get commitments from high level staff who will stay after the next election. 
Federal govt imposed Continuum of Care planning requirements for HUD Homeless Assistance Programs
Class action litigation for the homeless in NY created a right to shelter; forced public attention to homelessness and imposed costs (for which supportive housing could be a cost-effective alternative); similarly in some communities court orders to reduce jail overcrowding can create leverage to invest in community alternatives (increases the cost of status quo)
Change in technology: psychotropic drugs, supportive housing

## Key Requirements for Progress Toward a Comprehensive and Integrated Systemto Deliver Housing and Services 

**Develop infrastructure and leadership**
**Have full-time staff person(s) dedicated to integration**
**Conduct ongoing coordinated planning and support for implementation **
**Provide flexible funding **_**and**_** coordinate the allocation of categorical resources**
**Regularly update strategies and action steps**

## Anticipate and Overcome Obstacles to Systems Change

**Vested interests of entrenched and organized stakeholders who benefit from the status quo**
**Inertia of long-standing practice and habits – and pride about current expertise**
**Poor understanding of new system and its advantages**
**Distrust and uneasiness between people who need to collaborate**
**Stigma about the people we seek to serve**

**Notes:**
Acknowledge –state applications reflect some understanding of these obstacles – but just making a commitment to interagency coordination won’t make these go away –work to address these will be part of the work to get to a changed system – need to anticipate some normal growing pains as these get in the way of making and sustaining progress on the plans developed here at the Policy Academy.  
Don’t overlook – will probably need to pay attention to most or all of these!
Discuss concrete examples (and strategies that have been effective)
To address distrust and uneasiness – look at what has been learned in work on social capital and working effectively with diversity (use handout on forming new collaborative relationships); 
As we talk about programs, funding streams, eligibility rules, also recognize that systems change is about changing the behavior of people who may be defensive and uncertain about having their jobs (duties, roles and power) re-defined

## Obstacles to Anticipate and Overcome (more)

**Evidence-based programs may be politically difficult to establish – especially when they challenge approaches based on values and moral judgments**
**Existing programs lack adequate resources to meet current mandates / demands, making it hard to change in response to demands perceived as “new” or additional**
**Complementary programs and services are uncoordinated **

**Notes:**
Discuss concrete examples
e.g. 
CA AB 2034 law enforcement (& conservative downtown businessmen) as champions (in partnership with MH & homeless services); cite evidence re: assertive engagement and continuity of care as alternative to traditional substance abuse treatment which excludes people who are using 
Look at evidence of costs of current approaches – show how new approaches will allow better use of scarce resources (e.g. SFDPH: homeless people highest users of hospital ER, savings attributable to supportive housing designed to reach this group)
Collaborative planning instead of last minute discharge planning – design and manage implementation of a system that has the right components and the pathways between systems (e.g. hospital case mgt includes S+C eligibility; add respite) and create accountability for cross-system goals and outcomes

## Systems may lack capacity or infrastructure to act in new ways

**Data is not integrated**
**Staff in different systems don’t share common language, skills, and training**
**Few ongoing cross-systems planning and goal-setting structures are in place**

**Notes:**
Look for capacity / infrastructure that may have been implemented to support integration for other target populations with complex needs – and potential payoff for other priority populations from efforts that focus on chronic homelessness 
Data: start by tracking housing status of all consumers in mainstream programs that serve vulnerable populations (hospital uses homeless zip code)
Coordinated data: still an unsolved problem but there are reasons to be hopeful over the next decade.  Technology has improved and costs are declining; expectations for information availability have increased; new government mandates (e.g. HMIS) but need common data elements and requirements across federal agencies (e.g. HMIS and Medicaid or TANF)
Staff: some cross-training but most effective when hire 1 person from other system and let them become an insider (e.g. Dept Health hires experienced housing person)
Develop and sustain collaborative planning and implementation structures: e.g. CA SHIA, CT

## Overcoming the Obstacles

**Persuade by helping people recognize the costs of status quo – and see how they will benefit from changed system**
**Overcome with power and/or compromise**
**Cultivate champions credible with skeptics and opponents**
**Change attitudes with first hand encounters with the solution – show the effects of a changed system**
**Coordinated planning, linked with ongoing support for implementation and accountability structures**

**Notes:**
Discuss examples

## Elements of a Comprehensive and Integrated System to End and Prevent Long-term Homelessness

**Effective continuum of care**
**Collaborative planning & oversight**
**Investment & leveraging resources**
**Public: mainstream & targeted assistance**
**Private: philanthropy & business**
**Integrated, coordinated & streamlined funding**
**Integrated data / evaluation system**
**Provider capacity**
**Quality assurance and monitoring**
**Leaders / champions for changed system in strategic places of power**

**Notes:**
Pathways: Need not only the components of a continuum (prevention, outreach, emergency & permanent / supportive housing, with a full range of services) but also the pathways so that real people (with lots of problems) can get from emergency or transitional settings into permanent housing without bottlenecks that result in inefficiencies (staying in intensive transitional programs they no longer need) or failures (e.g. when people graduate from treatment programs but have no housing to sustain recovery).  This will require modifying wait list procedures or priorities for service.
Examples:  SFGH case management program for high utilizers became Shelter + Care outreach agency; DPH established Direct Access to Housing program
Mainstream programs – involvement is critical for prevention of homelessness (tracking housing status and outcomes for all participants) and for services linked to affordable housing for people who have been homeless.

## Effective Continuum of Care

**Substantial system-wide planning for homelessness, including all homeless-specific programs and services**
**Significant involvement of mainstream agencies responsible for services to people at risk of homelessness**
**A full Continuum with well established pathways for people to get what they need when they need** **it**

**Notes:**
Assume audience knows what pieces are in the Continuum of Care
Pathways: Need not only the components of a continuum (prevention, outreach, emergency & permanent / supportive housing, with a full range of services) but also the pathways so that real people (with lots of problems) can get from emergency or transitional settings into permanent housing without bottlenecks that result in inefficiencies (staying in intensive transitional programs they no longer need) or failures (e.g. when people graduate from treatment programs but have no housing to sustain recovery).  This will require modifying wait list procedures or priorities for service.
Examples:  SFGH case management program for high utilizers became Shelter + Care outreach agency; DPH established Direct Access to Housing program
Mainstream programs – involvement is critical for prevention of homelessness (tracking housing status and outcomes for all participants) and for services linked to affordable housing for people who have been homeless.

## Effective Service Delivery Systems to End Long-term Homelessness

**Outreach to effectively engage people who often do not enter or successfully complete treatment **
**Integrated treatment for co-occurring mental illness, substance abuse, and other health problems**
**Culturally relevant services**
**Consumer-centered services**
**New service strategies require workforce and organizational development to build new skills and infrastructure to support new programs**

**Notes:**
Recognize the need to build service system capacity to work effectively with this target population -- most current service & housing systems need more than resources – they need to build their capacity to effectively serve this population, which has needs / challenges that are more difficult than those addressed in most current programs.  Solutions require more than doing more of the same thing, or doing the same thing in a more coordinated way – also need new techniques, skills, and organizational/ workforce development

## Collaborative Planning:  Process

**Build relationships and common language across systems**
**Get commitments including resources to carry out the plan**
**Approval by elected officials**
**Develop a working structure to carry out the plan**

**Notes:**
Involvement of key stakeholders: Ensure broad participation 
Executive Branch Leaders
State and local departments of Housing, Mental Health, Substance Abuse, Health, Medicaid, Welfare/Social Services, Education, Homeless, Transportation, Labor, Criminal Justice
Senior-level staff with authority to make policy and budget commitments
Elected officials (e.g. legislators, city council members)
Providers of housing and services
Homeless or formerly homeless persons
Family members
Advocacy groups
 Michigan state partnership provided grants to local partnerships for collaborative planning to ensure broad participation in supportive housing projects

## Collaborative Planning:  Content

**Identify the need (types of households, geography, service needs, etc)**
**Establish numeric goals to meet identified needs within specified time period**
**Develop a strategy for community participation and education**
**Develop a cost analysis for the goals and strategies**
**Develop MOU that documents roles, responsibilities, and commitments to implement the plan**

**Notes:**
Our work has focused on supportive housing – but this applies to other comprehensive planning processes that integrate services and housing across multiple systems
MOU development – the process of negotiating roles and commitments is more important than the document itself – though MOU is also a tool for educating other stakeholders and ensuring continuity as people change. 

## Investment and Leveraging Resources:Process

**Identify funding needs and existing and potential funding sources**
**Identify how existing funds could be used differently (integrating, targeting, allocation)**
**Identify potential for new funds**
**Develop solutions to technical problems**

**Notes:**
Usually integrated service strategies rely on a combination of new funding and re-directed or integrated use of existing categorical resources

## Allocation of discretionary funds (state or local General Fund tax revenues)
Target “mainstream” Federal funds (e.g. TANF, block grants, HOME, Section 8)
Dedicated funding streams not subject to annual appropriations (Trust Fund, statutory set-aside)
New financing models (Medicaid, managed care)
Fund-raising (philanthropy, business)

**Target “mainstream” Federal funds (e.g. TANF, block grants, HOME, Section 8)**
**Dedicated funding streams not subject to annual appropriations (Trust Fund, statutory set-aside)**
**New financing models (Medicaid, managed care)**
**Fund-raising (philanthropy, business)**

**Investment and Leveraging Resources:****Content**

**Notes:**
Where systems change has been successful – all or most of these have been explored – cannot rely on targeted homeless assistance alone but need to target other resources

## Integration, Coordination and Streamlining Funding

**Inter-agency partnerships**** **
**documented in written agreements**
**top-level commitments and broad-based recognition and support**
**Inter-agency council or formal on-going structure to provide centralized authority**** **
**Coordinated articulation of funding priorities**
**Coordinated or pooled funding applications and decisions**
**Commit matching funds to leverage new resources for identified priorities**

**Notes:**
DON’T leave it up to project sponsors to figure out how to integrate funding from different agencies to meet your established priorities

## Creating Housing Opportunities to End Long-Term Homelessness

**Coordinate funding decisions for housing and services based on shared priorities and established goals**
**Multi-year funding commitments**
**Support for siting and community acceptance**
**Manage projects as they move through the pipeline (planning, development, occupancy)**
**Targeted outreach and ongoing communication to ensure that people in priority target population get and keep housing (reasonable accommodations)**

**Notes:**
Managing the pipeline may be done at the state level if projects are directly funded by state government, or by local government – often requires city/county partnerships (across levels of state/local government as well as between sectors)

## Quality Assurance and Monitoring 

**Establish consistent data collection, performance standards, reporting requirements**
**Create single point of accountability for integrated services and housing outcomes**
**Tie funding to quality assurance with participation by state or local government**
**Cross-training **

**Notes:**
consistent reporting requirements for multiple funding streams based on shared goals
State funding tied to participation in QA and/or local oversight of quality
Cross-training 
for providers (e.g. staff in supportive housing participate in training for MH staff)
for staff from public agencies involved in monitoring (e.g. MH and housing agencies)

## Recognizing Opportunities for Systems Change

**Those in power are dissatisfied or frustrated with the current system**
**Current system is in financial trouble or headed for trouble**
**New / better methods for doing things are beginning to appear in the field**
**Convincing evidence emerges, showing that new methods work**
**People in the system show interest in new methods**

## Looking Ahead:  Systems Often Don’t Change at Only One Level

**It’s hard to change systems working only at the state or local level**
**Federal programs, agencies, rules and incentives are part of state and local systems**
**State government is part of most local systems**
**Profound lasting change usually develops best at multiple levels**

*Never doubt that a small group of thoughtful committed citizens can change the world.  Indeed it’s the only thing that ever has.*
- Margaret Mead