The Power Of A Generative Ecosystem in Health and Human Services

“It takes a village to raise a child.”

And these days, it takes a network of villages – an ecosystem – to generate new levels of impact on people’s well-being. While tapping into the incredible resources of such an ecosystem is complex, digital technology and passionate people can make it happen. That’s the vision of the health and human services agencies in the US. It’s about creating thriving families – healthy, educated, and safe ­– at the heart of ecosystems because a child thrives within the nucleus of family. An ecosystem in this context is a set of organizations, systems, and services networked to create better outcomes. Health and human services agencies exist to harness the capacity of the ecosystem to create and sustain these environments and to identify and solve the root causes that challenge this vision. It’s a lofty goal, and one that inspires, challenges, and energizes an amazing group of public service leaders, as evidenced at the Health and Human Services Summit hosted by the Technology and Entrepreneurship Center (TECH) at Harvard University, developed by the Leadership for a Networked World in collaboration with Accenture and the American Public Human Services Association (APHSA).

Agencies that can collaborate and show impact on outcomes such as decreasing heart disease and childhood obesity (e.g., San Diego, California), curtailing the opioid epidemic (e.g., Kentucky), or reducing neighborhood crime through local efforts in Mecklenburg County, North Carolina earn legitimacy – the right to operate in a democratic society. Just as private companies are beholden to customers and shareholders, public agencies are tied to their constituents. Therefore, the organization, ecosystem, and services of health and human services agencies need to be centralized and focused on the family. That’s the motivation that brings agency leaders together at the summit to share what’s working and explore how to keep evolving to break down barriers within and between organizations and the public they serve to create effective ecosystems. At least year’s summit, 92% of the attendees said that building new ecosystems is critical to create change because of all the touch points with individuals in communities and the limited resources they have to engage.[1] This year, over 70% of the agency leaders in attendance said they anticipate a significant or extreme increase in the expectations to deliver better outcomes, and that ecosystems play a critical role.

During the two-day summit, leaders from health and human services agencies in the US and Canada explored what makes an effective ecosystem – who (people) and what (data and systems) need to be in it, how to use it to achieve better results, examples of work underway, and what organizations are learning. What is really happening in assembled teams to create the future? What does the future of outcomes look like and how do we create it? How do you get more impact from constrained capacity? Because, bottom line: The public wants to not just know but feel the value generated by its government, which depends on how health and human services agencies create collaborative ecosystems to harness, focus, and increase capacity to deliver better outcomes. That means, as Paul Fleissner, Director, Olmsted County Community Services summarized: “We need to focus on the person, and they don’t come in pieces the way we are often organized to serve.”

Successful health and human service agencies create ecosystems that enable families to thrive

When it’s good it’s really, really, good… In one example, the members of a health and human service ecosystem came together to support a family in trouble. Four kids and a mom from a violent relationship, homeless, became the nucleus of an effective ecosystem that included the legal system, human services, transportation, and education entities all working with the family. They polled, communicated, and supported each other to keep track of and support the kids and parent. These kids are now a distinguished academic, an artist, an accountant, and a US Army officer.

… and when it’s bad, it’s horrid… In a separate and unfortunate situation, US marshals visiting a house with an eviction notice found four kids who had died. Their mother had been on food assistance, rental assistance, and in a program for mental health issues, and the kids had been receiving transportation aid to get to and from school. All of these public services – and yet no single element of the system had raised an issue or alert or (evidently) communicated with another when the students didn’t show up at school or the mother didn’t show up for a mental health appointment. It’s a truly sad and unfortunate case of a broken system.

These stories each serve to show the criticality of working across organizational silos and bringing together services, technology, and people that focus on educated, healthy, and safe families. In the second example, the system was broken – likely organizations working in silos and according to their own processes. In the first example, each of the organizations put the family first, and it drove their interactions and communications because they all shared that focus. It led to better outcomes. As one of the agency leaders at the summit summarized, “Don’t look at the network internally… look outward at the customer… and focus externally.”

Rodney Adams, Director, Department of Community Resources in Mecklenburg County, North Carolina, shared how the department has developed a more community-based model for government operations. To reconstitute how they bring services to the community, they are realigning services to be in the community and interact with the locals, admitting, “we don’t have all the answers and solutions, but we can get there collectively.” Rodney facilitates the integration of public health, child support, veterans, and social services with local civic leaders and nonprofits, opening six centers in the neighborhoods to operate as a part of the community. Rodney shared that “when we talk about sharing resources, people feel threatened, but we have tenacious leadership committed to changing the way we work on the ground together.” To support the activity and focus, they are working with partners to develop a system to converge data for a local view to better inform decisions “on the ground.” Before getting to a point where they could have a shared system, they needed a shared environment – to create relationships and trust in the neighborhoods and between the groups involved in serving community members.

Developing a strategy for a generative ecosystem

It’s not enough to have a network of partners all focused on a shared person or group such as a family. A generative ecosystem – one that drives sustainable outcomes – needs to also have a strategy and a culture. At the summit, we talked about three elements of a generative ecosystem strategy:

• Social: Targeted and measured outcomes that are consciously shared, such as a safer community with metrics around reducing crime;
  
  
• Technological: Technology such as software and machine learning for capturing and analyzing data for patterns, alerts and transaction processing; use of technology that is not the “end” but the “means” to achieving impact, as seen in the example of Mecklenburg County first coming together in partnership, then looking at the technology;
  
  
• Economic: Evidenced-based valuation models and pay for success, etc., an emerging area of focus for grants and public funding, for example, and in healthcare as seen in the next example.

Organizations working through this type of strategy include the New Mexico Human Services Department, which is on a journey to reframe its Medicaid program. Healthcare generally is undergoing a transition from fee for service (e.g., doctors get paid when someone visits the office) to value-based care (e.g., networks of doctors, therapists, etc. getting paid based on the results of the care they provide). To drive this kind of care, the health care industry needs to be patient-centered and put people at the core. People’s health and well-being, the effectiveness of care, is not just dependent on the care plan of the patient, but also on the individual’s environment. For example: Can the person get to a doctor’s appointment for follow up? Do they live in a house with others or are they alone? It’s not just about health but also about human services.

For New Mexico, Brent Earnest, Cabinet Secretary, described how they put the patient at the center of Medicaid reform and took a view to work across health and human services to create an organizational and technical infrastructure centered around people. They are working through questions of how to understand the needs of individuals, what data they have or how to fill the gaps, how to mobilize Medicaid recipients, as well as how to change flexibly with policies and regulations. Bottom line: They have developed an ecosystem around the intent to increase the health and medical outcomes and reduce the cost of health care by considering the person in the system – their social, economic, and environmental characteristics, all of which have an impact on the status and cost of their health.

The role of culture in sustaining the ecosystem over timeWe can also learn from the work underway in other jurisdictions. While it is important to consider policy and regulation, we are in an ever-changing world, where horizontal efforts are critical to addressing complex problems. Jill Vienneau, Ministry of Community and Social Services in Ontario, Canada is leading an effort to build an ecosystem and infrastructure to better integrate social assistance, childcare, and affordable housing and homelessness prevention. “Putting our client at the center of the work we do helps to get us out of program management mode” she said. We tend to have a clearer focus on the client when there is a sense of urgency. In 2015-2016, Ontario settled over 10,000 Syrian refugees in less than a year. This required levels of government, agencies, and service providers to break down barriers to settle the refugees, and sustain support for the refugees. The challenge is “when you don’t have that sense of urgency, how do you drive change, be innovative and think creatively over time?” Keeping the client or person at the center of the work is a key success factor. Culture also plays a role. It’s not enough to have a strategy to share goals, data, systems, and processes, or even communicate regularly – government and agency leaders need to behave in a way that taps into and brings together people’s passion, focus, and tenacity and sustains it over time.

The way people in the ecosystem behave determines whether or not the strategy will lead to the desired outcomes of healthy, safe families. For sustainability, the summit group reflected on the need to continually consider whether the members of your ecosystem have a shared outcome, how you are best using the technology that is available and emerging, and if you are having the desired impact. These points are all manifested in people’s behaviors and the organization or ecosystem’s norms or governance – the culture. Ecosystems also need to have a personal element to be engaging and generative. “The knowledge you are asking people to transfer is not what you can put into a spreadsheet and send via email,” said Dr. David Ager, Harvard Business School. “It is nuanced and has behavioral aspects; it takes time. Be willing to sit down and work together at the level you want and need. And, you need to be able to re-prioritize for the good of the collective, for example your boss has to say it is ok to deprioritize X because the bigger goal matters more.”

How an ecosystem’s breadth, depth, and density lead to impact on shared outcomes: The story of Live Well, San Diego!

Dr. Ager suggests that every network needs three elements:

1. Breadth: Incorporate different kinds of people, e.g., age, gender, culture, agency representation, depth of experience, private and public sector, across state lines, skills and capabilities, passions and interests;
   
   
2. Depth: Balance a closeness of relationships – some strong ties that ensure reliability under conditions of uncertainty and some weaker ties that provide useful information for accomplishing specific tasks;
   
   
3. Density: Look at the links between non-intersecting networks… does one group intersect to another group and how dense (may signal redundancy) or sparse (may undermine trust).

An example of how a network of developing breadth, depth, and density can create a culture that is increasingly integral to achieving a shared vision and outcomes is in San Diego County, California, where a generative ecosystem is building on the foundation of “Live Well San Diego!” In 2010, this initiative started with the County of San Diego’s Health and Human Services Agency and the approach is now integrated into the way the rest of county government works, including strategic planning, budget allocations and policy changes, as seen in its annual reports. Anyone can review the targeted outcomes and metrics the government is using to chart the progress of having healthy, safe, and thriving communities. Nick Macchione, Agency Director, Health and Human Services Agency, County of San Diego, described how the movement has gained momentum over the past seven years to get the current point of breadth, depth, and density working as a “human serving ecosystem” of 315 partners including businesses, schools, cities, non-profits, community and faith-based organizations, with governance, “harmonizing hearts and minds of people to take action in helping all people live well.”

An ecosystem focused on shared outcomes can help change policy

San Diego put together a visionary model that started and grew in the regulatory space; it challenged the norms. The model required transforming the way that core competencies were approached, including strengthening the service delivery system, effecting policy and environmental change, supporting positive choices, and improving the culture from within one’s organization. They also proposed areas of influence (e.g., health and knowledge) to be measured by a series of key indicators. Driving change to policies took coordinated and collaborative effort. The county board of supervisors, its senior executive leaders, and HHS staff had to take a risk and make the vision the foundation for change – Nick describes it as having “one hand on regulatory and the other stretched to the vision.” He added, “We talk about whether or not policies are human serving and adding positive value; we work with government leaders to show how everything we do, and the policies around it, impact people’s lives.”

This movement did not start with partnerships or policies in mind – it started with how to organize the 6,000-employee health and human services agency around living well, with the conviction that it is the right thing to do, too, for their families and neighborhoods, and that was the starting point to branch into the community, first with a partnership with the City of Oceanside in 2001. This one was significant because there hadn’t been much alignment in other health policies with the City of Oceanside. Wellness was the unifier – to address issues around adult and childhood obesity.

This initiative expanded into a number of areas, including the Chula Vista Elementary School District there has been a significant drop in obesity rates. Compared to 2010, when the district first collected Body Mass Index data, the number of students in the obese category decreased by 17% by 2014. The number of students in the normal weight category had an increase of over 7% percent during that same period of time. This represented a 24% improvement of healthy weight children for a school student population of nearly 30,000. Many of other initiatives by Live Well partners have a set of shared and measured outcomes to help create focus, a case for change, and momentum to scale the effort.

All organizations have their own governing boards, egos, and beliefs, but they always come back to the unifier – health in all policies – to drive discussions toward give and take to reach the shared outcomes. As another example of impact -- in San Diego, heart disease has moved from the first cause of death to the second. The goal is to be a “heart attack free” county. And now the expanded ecosystem touches over 2.5 million San Diegans. That’s power that can help drive more change, including challenging indicators around poverty, crime and income.

How does an ecosystem start?

How the opioid crisis spurred an ecosystem to leverage resources and insights in Kentucky

One clear incentive for an ecosystem is to pool resources to solve a shared problem – which is how a maturing ecosystem took root in Kentucky in 2016. Opioid overdose is now the leading cause of accidental death in the US – more so than vehicles or guns. And, in 2016, Kentucky was in the top five states with deaths caused by opioid overdose and saw an outbreak of hepatitis in a nearby state with similar demographics. This crisis ignited a new ecosystem in Kentucky.

Kentucky has been actively addressing opioid use disorder for many years; however, Governor Matt Bevin’s administration is leading a response that is more comprehensive, coordinated, and data driven than ever before. The infusion of over ten million dollars into the Kentucky Opioid Response Effort and the state’s Medicaid reforms focused on substance use disorder are clear examples of Governor Bevin’s commitment to overcoming the opioid epidemic.

Kentucky is one of the poorest states in the US (47 out of 50), more than 50% live in rural areas, and over 1 million of the 4.4 million residents are on Medicaid. These factors do not necessarily paint a profile of who and where to target for intervention because opioid addiction and overdose is an issue across economic and social factors. Agencies in the state all had different perspectives on the issue – each entity produced its own reports and made requests for funding based on how their agency felt they needed to address it. They lacked a common terminology, centralized staff, and integrated infrastructure.

To define the shared problem and desired outcome, the agencies turned to the data – it’s fact, not politics or emotion. The data shows how Kentucky resident drug overdose emergency department visits where heroin was a factor was skyrocketing, and where other drugs were a steady factor. The data also shows the counties where overdose deaths were high – some areas having over 100 deaths in 2016. Over time, it was also the data that showed the impact of joint efforts by the state to address the crisis.

When the agencies in the state increased the coordination based on a shared set of outcomes – educated constituents, more controlled physician prescriptions, reduced instances of overdose, reduced hospital stays and readmissions associated with opioid use – they started to make progress and attract other entities into the ecosystem, such as universities and insurance companies. In Kentucky, Aetna has been using its own internal data and partnering with external companies to implement strategies for improving health outcomes based on analytics. The data illustrates where gaps in care may be occurring and the avenues in which Aetna can deploy additional resources in order to support a healthier ecosystem.

Each member of the ecosystem has a part of the story and bringing the data together helps in the collective use to shape a solution. During the summit, members of the Kentucky team each painted the same picture of the crisis overall – but from different perspectives. On the one hand, it showed the complexity of having many moving parts, and on the other hand, it showed the richness of the resources and passion when you can bring these pieces together. Each one had a set of different set or view of data that all defined the shared problem – Kentucky was in the top five states in the US for opioid addiction and overdose and that is not acceptable. This last driver is what united them in a shared effort to eliminate the crisis.  

A generative ecosystem needs metrics – and care and feeding

To be effective and sustainable, an ecosystem has to be managed and nurtured … a balance of personal and professional interaction. A few guiding principles that emerged from the two-day session and covered in examples include:

• Build the ecosystem around a shared problem and desired outcome, and revisit both regularly; have metrics in place but also stories – the combination of stories and numbers is compelling, as is seen in the Kentucky example.
  
  
• Celebrate successes and results throughout – it gives people a feeling a momentum from the change, and a feeling of being part of something successful; San Diego does this by sharing the success stories and profiles of participants online and at events.
  
  
• Learn what matters to other members of the ecosystem to engage and keep them participating in reaching the outcome, such as the way the network is growing and strengthening in Kentucky between agencies, universities, and the private sector.
  
  
• Talk regularly to the people intended to be impacted – use a human centered design; listen and respond, the way that Mecklenburg County health and human services is operating within the communities now.
  
  
• Use data and analytics to both tap into but also filter out emotion. Sometimes emotion has a strong play for participating in an ecosystem, but if the numbers don’t unify the group toward a common goal, everyone can read the numbers in their own way and not make progress on the outcomes. There must be a feedback for analyzing the data, as in the case of Kentucky addressing the opioid crisis.

Be bold. Change requires courage. As one summit attendee reminded everyone, “Leadership has to be vulnerable, take risks, and go first…”

Find innovation inside, outside, and all around everyday work

Creating a future of innovation and impact, the theme of the summit, stems from the right culture – behaviors and governance all focused on shared outcomes, enabled by data, analytics, and technology. If there is a culture of change – where behaviors and governance provide a structure and “allowance” of time, energy, and resources, then ideas will flourish into innovation. The reality though, is that there are challenges in restrictive policy, legacy technology, and organizations and employees who are used to working in certain ways. “Often, we are asking our teams to do work that is not funded, has no R&D support… how do you direct resources to the new and also do the work that keeps the ship sailing? Also, traditionally you get paid for playing by the rules not for being innovative,” challenged Angela Bovill, President and CEO of Ascentria Care Alliance. She answered her own question for the group, “We have great ideas and we have resources – let’s bring them together in an ecosystem.”  Today’s version of “it takes a village to raise a child,” is that it takes a generative ecosystem nurtured and managed by health and human services agencies to foster healthy, thriving, and safe families.

[1] HHS Summit: Moving Toward the OneOffice Endgame: https://www.hfsresearch.com/pointsofview/hhs-summit-at-harvard-moving-toward-the-oneoffice-endgame