A Mindset Shift to Sustainable Health
Wide-reaching, multi-faceted, frustrating, confusing, and messy social issues — such as homelessness, income inequality, and the opioid epidemic — seem to defy all efforts to tackle them. Current systems thinking practice maintains that these multi-system issues require a different approach to teasing out potential ways to help those in need, say experts in the field, such as the co-founders of the Systems Sanctuary, who consulted on this collaborative.
Systems thinking is designed to go beyond immediate, band-aid style, quick-fix solutions to delve deeper into the underlying patterns that are preventing endurable, sustainable change, practitioners say. Systems thinking is a process or mindset that is predicated on learning, leveraging, and adapting, all in the service of bringing about lasting systemic shifts. Its underlying principles: seek health, see patterns, unlock change, and pivot as needed, according to systems-thinking evangelists from the self-styled philanthropic investment firm The Omidyar Group.
“Systems mapping helps to articulate nuances and effectively express the complexity of problems to engage new stakeholders and individuals,” says Barker. It’s particularly useful, she says, to build bridges and connect with other stakeholders to avoid an “us versus them,” dynamic, between, for example, people with living or lived experience and law enforcement personnel. “It honors the gray areas and makes it easier to find the ‘we’ even if the ‘we’ is complicated,” adds Barker, a registered dietician/certified diabetes educator by training who knows from both personal and professional experience the challenges of working with behavioral change.
In the midst of this project, Barker found herself becoming a person with lived experience. She lost her husband, who struggled with depression, anxiety, and, more recently, a substance use disorder. “This is deeply felt work for me,” Barker says. “I know you can’t succeed without engaging families and listening with an open heart.”
A System Under Siege
As part of the CCI initiative, SafeRx Santa Cruz County participated in a systems mapping workshop in July 2019 led by the co-founders of the Systems Sanctuary, human-centered design training facilitated by CCI coach consultants, and held its own workshop to get a better handle on the needs of its community. SafeRx also wanted to figure out what strategies and solutions the group should prioritize in dealing with drug addiction in the county. Funded in partnership with California Department of Health Care Services, the initiative was designed to help facilitate collaborations between opioid reduction coalitions and community stakeholders, such as health care providers, local citizens, government agencies, first responders, and residents in recovery.
Launched in late 2015, SafeRx Santa Cruz County is a program of the Health Improvement Partnership of Santa Cruz (Barker is a program director there) and funded by the California Health Care Foundation. Its mission: to decrease the misuse of opioids and opioid-related deaths through safer prescription practices, improve access to medications for addiction treatment (known by the acronym MAT), and increase availability of overdose reversal medication, such as naloxone, known by the brand name Narcan. SafeRx is rooted in the philosophy that the medication has failed the patient, not that the patient has failed the treatment.
The coalition is focused on doing work to help shift the culture of prescription medication from one of high prescribing and use, to one of judicious prescribing and improved health, while ensuring a safe and compassionate community for patients, medical and behavioral health providers, and residents, Barker explains.
Santa Cruz reported 29 opioid-related overdose deaths in 2019, the most recent calendar year of data available, according to the California Department of Health Services. This represents a 61 percent increase from 2017. There were 128,886 prescriptions for opioids (excluding buprenorphine) in Santa Cruz in 2019, which represents a 20 percent decrease in prescribing from 2017. Over the same time period, buprenorphine prescriptions in the county — which are used to gauge the expansion of MAT —increased by 26 percent.
Opioid use disorder represents the deadliest drug epidemic in US history. In addition to the devastating effects on the health of individuals, families, and communities, opioid use disorder is also a major driver of high-cost health and medical service utilization, such as inpatient and emergency department care. The epidemic has caused an enormous economic burden on health and other government systems.
It is important to hear the voices of the community affected by the opioid epidemic. This video, created and presented…
Posted by SafeRx Santa Cruz County on Monday, January 23, 2017
Mapping to Make Sense of a Messy Matter
Enter systems thinking. From System’s Sanctuary’s Tatiana Fraser and Rachel Sinha, SafeRx Santa Cruz County learned that systems mapping is all about shifting dynamics, structures, and relationships. The goal of this work isn’t to look for a solution off the bat — or lay blame — but figure out why something is happening, often for a complex web of social, economic, cultural, and environmental reasons.
Armed with this knowledge, SafeRx hosted an in-person October 2019 mapping session, where for three hours around 50 community stakeholders brainstormed new pathways to better address substance use disorder. In the room were representatives from the sheriff’s department, local hospitals, safety net clinics, and members of the local Harm Reduction Coalition of Santa Cruz County, which distributes clean syringes, other supplies, and the overdose-reversing drug naloexene in the community. Every participant stayed the whole three hours for the workshop and participated in the exercises, according to the SafeRx team. “There’s something very rich about the systems mapping approach,” says Barker. “It can meaningfully engage more diverse stakeholders, gather input and responses more efficiently so it’s possible to see and understand more deeply a particular problem.”
Case in point from the workshop: Barker says she and her colleagues were able to get a clearer picture of the particular challenge of multiple substance use disorder, primarily stimulants, and how it is a growing problem to many different stakeholders. The coalition formed a poly-substance work group as a result of the workshop to prioritize the problem and had its first in-person meeting the day before the March 2020 lockdown. Barker said, “The mapping session also prompted deeper work on existing efforts with emergency departments/hospitals as well as our work to support/launch MAT in jails.”
“Systems mapping is a great way to look at the system as a whole, the interplay between the individual pieces, and how they fit together,” says physician Jen Hastings, medical lead for the SafeRx Santa Cruz team and the former medical director for the Transgender Health Care Program for Planned Parenthood Mar Monte, which includes Santa Cruz. “They’re really cool tools.”
Without the systems mapping workshop, Hastings says it’s unlikely the coalition would have cast as wide a net to engage stakeholders and would likely not have had as successful a convening. “Systems mapping engages you to go further out and deeper in at the same time.”
Mapping and MAT
That’s not all. In the course of the collaboration, the coalition also discovered ways to work more closely with law enforcement personnel, court representatives, and school district officials. For instance, by inviting the sheriff to a systems mapping workshop, the coalition learned that he was open to introducing MAT into the county’s jail. That was big news for the coalition. “We already knew there was a need — we routinely see or hear from people coming out of jail having experienced horrific withdrawal,” explains Hastings. “We assumed that the sheriff wouldn’t support MAT in the jails,” adds Hastings, of a sheriff’s department that has come under scrutiny for its medical care of incarcerated people.
That wasn’t the case. At the systems mapping workshop Sheriff Jim Hart went on record that he believed in MAT, and had wanted to introduce it for years, according to Hastings. “His buy-in, in a public setting, with a group of 50 witnesses was huge in this small community. We knew we would be able to keep moving forward with MAT in the jail after that event.” A MAT program for all Santa Cruz County jail settings was introduced in July 2020 with the support of Health Management Associates, a national consulting organization whose focus includes supporting MAT in the criminal justice system.
It’s an evolving partnership, says Rita Hewitt, SafeRx Santa Cruz’s program coordinator and co- lead on the CCI initiative. Hewitt considers these first responders new actors in the systems thinking mindset. The coalition has worked with law enforcement to implement a jail-house program, including providing Narcan for people who are incarcerated. “The best thing to come out of that meeting wasn’t so much how can we help them,” says Hewitt,” but how they can better understand empathy, stigma, and harm reduction.”
Community organizations facing widespread drug use see increasing access to MAT as crucial, and this is a major focus of local opioid community coalitions. In California, for instance, several counties have introduced or are considering introducing MAT into their incarcerated communities. Studies have shown that medications for addiction treatment (typically methadone, buprenorphine, and naltrexone) reduces the risk of overdose deaths by 50 percent.
It’s definitely early days. What’s happening in the jail in terms of medical care isn’t trauma- informed or patient-centered, says Hastings. “There’s a lot of work ahead, a need to shift the culture. Systems tools may help us get there.” That said, they’ll take the small victories, including setting up a tri-county taskforce/collaborative — with nearby Monterey County and San Benito County — to work together on bringing MAT to the jails.
That’s been a silver lining of the pandemic, adds Hastings, who is not a fan of the phrase, but in this case it’s apt. Convening in-person meetings with aligned organizations would have been difficult, if not impossible, to organize due to geographic barriers pre-COVID-19. “We actually met more often in the first six months of the pandemic, as we needed to support each other to pivot to telehealth,” explains Hastings. “Online meetings are hard: We missed being together in person, but we found we had a lot to share and learn from each other. We built on our previous trust and connections with each other. I think we are probably stronger together because of the pandemic. We certainly have new and important relationships with persons we might never have met.”
Word Pictures for the Win
Systems mapping is not without its challenges. A new concept for many, it can take time to introduce the idea to participants and secure buy-in. The work is weighty, but dense and wordy.
That’s where a visual representation of all the ideas swirling around from multiple stakeholders can help organize thoughts, spotlight patterns, and reveal pathways. RxSafe Santa Cruz learned that firsthand at their systems mapping workshop, where they invited a graphic reporter to document the session. This in-house illustrator worked on several visual maps in real time that were finessed after the meeting, including one stunning, standout visual map summarizing all the ideas raised at the event. (Keep scrolling for the end result!)
The finished product, designed by graphic reporter, Leslie Salmon-Zhu of Bay Area-based group Conference Arts and Insights, elegantly and accessibly translates the coalition’s ideas and is intended to illuminate insights from the meeting in visual form. The artist provided a visualization of what the coalition does, what it wants to do, and how to move forward, says Barker. It’s a great image to share, she says, and helps to explain the process — and it’s the perfect vehicle to showcase the “we” in systems mapping.
At the completion of the workshop, the group viewed the visual representations of their work during a gallery walk around the warehouse room. “There was a rich sense of competency, we could so clearly see the fruits of our labor, our accomplishments, all gathered together,” says Barker. ”It was clear where there were areas we could collaborate, areas where there was duplication, areas that needed addressing.”
The word maps have been put to good use. “We’ve used the original professionally produced image of our mapping session as part of recent core leadership team conversations,” explains Barker, who says that decision-making body also created a simplified version. “In a nutshell, we’re using the mapping session to guide our strategic planning of next steps for the coalition. We’ve used both the original version and the simplified one as we’ve engaged more deeply with new stakeholders,” adds Barker, naming both Emergency Medical Services and County Office of Education as two examples here.
As the aphorism goes: a picture is worth a thousand words. In this case it’s a word picture:
The core leadership team of Rx Santa Cruz has simplified the proposed pathways from the systems mapping work and intends to implement these in 2021, with a particular emphasis on youth, emergency department settings, and MAT in jail. The coalition has also identified faith-based organizations, political appointees, business owners, and youth groups as stakeholders where the coalition needs to make meaningful connections. “We’re aware of what’s missing, where there is still a lot of work to do,” says Hastings. “But the spirit of ‘we’re all in this together’ is really there.”