Health Care

Teamwork, One State at a Time

November 17, 2016  • Michael Green

Improving population health involves a complex web of actors, including federal, state, and local officials; hospital systems; and community groups. But too often, the kind of collaboration that provides communities with the best results gets stuck in silos and mired in turf battles before it can even begin.

In 2013, the Institute’s Justice and Society Program, with support from the Robert Wood Johnson Foundation, created a pilot project designed to break down barriers to collaboration on state population health. Using our program’s knowledge of how state government works and the foundation’s comprehensive network of population-health resources, we designed the Excellence in State Public Health Law program, later renamed TeamWork: Leadership for Healthy States. Participating teams are led by top state health officials and include state legislators as well as staff from health departments, other state agencies, and governors’ offices. By this fall, 13 states across the country had participated in the program.

The teams each approached improving population health in remarkably diverse ways, identifying projects and strategies that are particularly relevant to their own states and tackling everything from easy-to-accomplish objectives to daunting challenges that have been on the back burner for years. Team Hawaii, for example, worked to improve dental care for Medicaid-eligible children. Team Arkansas increased community access to local exercise facilities by promoting joint-use agreements. And Team New Mexico focused on reducing food deserts in pueblos and tribal lands. According to one team leader, TeamWork offers participants breathing room to accomplish a project—providing technical assistance, dedicated time, and opportunities to convene—and it allows politicians, end-users, and advocates alike to claim a win on critical statewide concerns. This unusual opportunity for interagency and intergovernmental cooperation has given rise to an impressive amount of collaboration, innovation, and enthusiasm.

Team South Carolina is an exciting example. Christian Soura, director of South Carolina’s Department of Health and Human Services, was already familiar with the Institute’s leadership programs through his participation in the Aspen Global Leadership Network’s Liberty Fellowship. With the encouragement of State Senator Thomas Alexander, who later joined the team, Soura began a complex project he had long been hoping to undertake: a collaboration with the state’s Department of Corrections to enroll detainees in Medicaid before their release from incarceration.

In South Carolina, as in most states, people lose Medicaid coverage upon incarceration. When inmates, whose rates of chronic and mental illness and substance abuse are markedly higher than those of the general population, are released, the state provides a five-day supply of any regular medication and a one-month prescription for more. But their release date is a highly vulnerable moment both psychologically and medically, and they often leave incarceration with no “medical home” for primary care or any provisions for behavioral or rehabilitation services—let alone transportation to those services. It comes as little surprise, then, that so many former prisoners slip back into cycles of substance abuse, chronic disease, and mental illness—and then back into costly emergency rooms or correctional facilities.

Soura and one of his TeamWork partners, South Carolina Department of Corrections Director Bryan Stirling, thought there was a better way: begin the Medicaid reenrollment process early enough that inmates leave prison with a Medicaid card and a medical home. The two set about redesigning Medicaid’s interactions with their state’s Department of Corrections. Others on Team South Carolina laid the groundwork within their respective branches of government for legislative and regulatory cooperation.

The state was continuing to pay monthly premiums.

Along the way, Team South Carolina made a surprising discovery: as “guests of the state,” some prisoners erroneously remained on Medicaid rolls, meaning the state was continuing to pay monthly premiums, even though the prisoners were being treated in the prison health system and had no access to Medicaid services. By disenrolling those with coverage during their incarceration, the team was able to cover the project’s startup costs.
Team members also used the reenrollment process as an opportunity to assess the need for insurance services within the inmate’s immediate family, a valuable step toward reintegrating former inmates into their communities.

TeamWork was an essential part of the success of Team South Carolina’s project. “Our typical workday is consumed by the tactical—the next meeting, the next email, or the next phone call to return,” Soura says. “TeamWork’s dedicated time to work with other agencies on common health-focused priorities has renewed staff commitment while meaningfully benefiting society.”

We’ve learned some important lessons about what leads to success.

That staff commitment is serious. Team South Carolina’s Stirling, of the Department of Corrections, and Beth Hutto, of the Department of Health and Human Services, report that at both departments, staff members who were not on the team but learned about the project volunteered to put in extra hours. “It made them excited to come to work,” Hutto says. Stirling adds, “There’s a genuine desire among our correctional officers and all our support staff to help offenders stay on their feet once they return to the community. This project raises the odds that reentry will be successful.”

During TeamWork’s three-year run, we’ve learned some important lessons about what leads to success. The Aspen method of inquiry is one. Early readings on political philosophy, such as “The Ones Who Walk Away from Omelas”—a short story familiar to those who’ve taken the Justice and Society or Executive seminars—signaled that TeamWork was focused on creating solutions based on shared values. Additional focuses on collective impact and systems leadership pushed participants to expand their visions for intergovernmental collaboration and public and private engagement.
Leadership retreats and regular in-state team meetings also helped team members think creatively about complex population-health challenges in their states, rather than simply reacting to the latest emergency. A little collegial competition between teams also provided some healthy motivation. And TeamWork’s “health in all policies” approach meant that a state agency without the word “health” in its name could get in on the game, enabling crosscutting collaboration to incorporate population-health concerns into state policy decisions and strategic planning government-wide—a key element of the Robert Wood Johnson Foundation’s Culture of Health vision.

Collaborations to achieve health in all policies need not involve the usual health department suspects.

At the Justice and Society Program, we also learned a few things. Collaborations to achieve health in all policies need not involve the usual health department suspects. In fact, as demonstrated by South Carolina’s partnership between health and corrections departments, and by several other TeamWork projects, working across agencies that rarely share policy agendas can dramatically reduce the risk of battles over jurisdiction and funding. This opens up interesting possibilities for collaborations between health agencies and transportation, environment, and public-safety agencies.

We also learned how silos in state government can hinder smart policy. The TeamWork model engages the elected branches of government in a once-commonplace way—through a focus on a shared mission to provide more effective, efficient health care services. As Team Hawaii’s leader, David Sakamoto, observed at his cohort’s conclusion: “We witnessed a shift as we worked with legislators, from oversight to partnership and participation. It’s a different way of engaging relationships.” Former Washington Governor Christine Gregoire, a member of the Excellence in State Public Health Law Advisory Committee, agreed: “In the future, this may be the only way we get things done.”

Silos in state government can hinder smart policy.

Connecting over shared values brought team members back to basics and to the moral and professional commitments that led them to enter public service in the first place. TeamWork’s approach to leadership development has yielded several promising lessons—ones that can be adopted and adapted by state and local governments to address a variety of critical health and social challenges.