Thursday, June 21, 2018

Salem Health Suspends Service Integration Pilot

Revised: January 2019

By Sarah Owens and Michael Livingston

About this time last year, two service integration programs were launched in Marion County.  One by Santiam Hospital, the other by Salem Health, both modeled on Polk County's long-standing service integration program.  Hopes were high.

Today, however, only one of the programs remains faithful to the model and will continue next year.  The other, having relied on shortcuts and cheap fixes, is suspending operations, pending discussions with potential "partners."  The fate of this program's individual teams is now very much up in the air.

The story of these two programs, related below, is an object lesson on the danger of short cuts to high-fidelity replication.   

The story begins in early 2017, with a group of more or less like-minded individuals who, for a long time, had wanted to bring service integration to Marion County, based on the Polk County model.  We were members of that original group, which is how we came to be in a position to relate this story.  So was Sharon Heuer, the Community Benefits Director at Salem Health.

Sharon Heuer conducting info session in Stayton
Sharon was nothing but enthusiastic about the project.  She quickly took charge of the group, expanding the membership and chairing the meetings, which were all held at Salem Hospital.  By only the second meeting, she had appointed one of her staff to coordinate what would become the Salem Health pilot program.

By the third meeting, the practical and political problems with developing a team in the Salem-Keizer area were quite evident.  It would get too large and end up being just about the money.  And, what about the CPTs?  The group decided it would be best to start with a rural community, one with unmet needs, but organized enough to want assistance developing a team whose primary goal would be to coordinate the sharing of resources and information.  Sharon, however, was really wanting a team near the hospital, so, at some point, it was decided that there would be two pilot teams, one in a rural community, the other inside the Salem-Keizer School District.  In March, we issued a request for applications.  The RFA went out over the name "Marion County Service Integration Teams."  Certain Marion County officials didn't care for that, so the name was changed to "Service Integration Teams of Marion County".  April was spent conducting information sessions at strategic locations.

Out of the information sessions, it came to pass that Santiam Hospital decided to start its own service integration program, with its own webpage, its own logo, its own coordinator and its own teams.  The Santiam Hospital program coordinator and the Salem Health program coordinator, both of whom were on the steering committee, were to work together, and with the Polk County coordinator, to maintain consistency across programs.  

In late July, Sharon announced that Marion County would have four teams, one run by Santiam Hospital, three run by Salem Health.  The steering committee had concerns about Salem Health's starting up three new teams all at once, but, Sharon was very confident and insisted it could be done.  At the very same meeting, she started talking about "sustainability" and applying for grants.  Over the next several meetings, we came to realize that she was talking about handing the program off to some other agency -- maybe United Way, WVCH, the county, MWVCAA, someone -- by the end of the year.

map as shown on SITs of Marion County website 
Looking back, we must have been very foolish to think that Salem Health was committed to its service integration program.  Sharon had never said that, not in so many words.  But, she also had never said that, while Salem Health strongly supported service integration as a model and has for many years been willing to provide direct-aid funding for teams in Polk County, what Salem Health doesn't do is undertake to run community programs long-term.  Had we known early on that Salem Health was not committed to maintaining the program long-term, we would have objected to having Salem Health run the pilot.  It probably wouldn't have made any difference to Sharon, but we would have objected.

Another dynamic we were slow to recognize was that Sharon had a very limited concept of service integration; as far as Sharon was concerned, all the coordinator needed to do was facilitate meetings and send out funding requests.  The rest was "SIT magic."  What Sharon never seemed to understand is that what she called "magic" was entirely a function of the coordinator's relationships with local providers, knowledge of local resources and ability to assess a situation and coordinate an appropriate response.  What Sharon called "magic" was, in fact, all the hard work that must be done before a funding request ever goes to the team.  Otherwise, it's not a service integration program -- it's at best a small grants program.  

The tension between the two programs began when Santiam Hospital said it wanted its own service integration webpage.  That really seemed to irritate Sharon, probably because it interfered with her plan to market service integration in Marion County using the website she was planning to develop. The idea was that "Service Integration Teams of Marion County" (the original name of the website and Facebook page developed by Salem Health, with a domain name, "SITsofMarionCounty") would be a sort of "umbrella" for both programs, with event calendars, resources, and links to forms, guidelines, and other basic information that was supposed to cover all the teams in Marion County.

Trouble was, however, the "umbrella" had Salem Health written all over it, meaning the website was designed and executed in such a way as to  make it appear that there was only one program, and it was operated by Salem Health.  Things got even more confusing when the Salem Heath coordinator rewrote the funding guidelines and published them without consulting anyone, including the steering committee.  We knew then that the program was in serious trouble. 

A successful service integration program simply must have an experienced, knowledgeable person to coordinate the teams full time, especially if the program is just starting out.  If all that was needed to succeed was someone to facilitate meetings and send out funding requests, then it might have made sense for Salem Health to reassign, on a temporary basis, an inexperienced part-time staff person with no aptitude to the coordinator position.  Of all Salem Health's misjudgments and short cuts, Sharon's failure to understand the importance of having a skilled, full-time coordinator was the worst. 

CHEC Support Group Room
After launch, the steering committee met monthly in the CHEC Support Group room.  Not everyone on the committee attended team meetings, but some of us did.  Those who did knew the problems.  Those who didn't apparently believed everything Sharon told them.

For Sharon, success was all about spending the money.  We tried to tell Sharon that the coordinator needed more hours and job shadowing or other training opportunities.  She just said everything was fine, except the teams weren't spending the money.  She never understood that the teams weren't spending the money because they weren't doing the work, and they weren't doing the work because the coordinator lacked the skills needed to guide them.

One way to know how well a team is functioning is to look at the team ledger, and the Salem Health ledgers were showing obvious problems.  They were also a mess.  But, as Sharon  liked to say, she's "not a detail person."  When the steering committee tried to weigh in, she just said "the regional group" (managers and coordinators of the Polk, Yamhill and Santiam programs) would take care of "operations" -- her way of saying she wasn't going to discuss it.  In fact, there was no "regional group" per se.  There had been one meeting, and talk of maybe meeting quarterly, just to check in, but that was all. 

Things finally came to a head over the Salem Health website.  A 1/31/18 article in the Statesman Journal referred to the Santiam Service Integration program as being supported by "Salem Health's Santiam Hospital."  When the reporter was asked where he got the impression that Santiam Hospital was Salem Health's, he said he got the "information" off the Salem Health website.

For months, Sharon had been told that using "SITs of Marion County" on the website and FB page was misleading and the name needed to be changed.  Even though the steering committee all had agreed it should be changed, she resisted -- she wanted her "umbrella."

The Statesman Journal article prompted a letter from the CEO of Santiam Hospital to the steering committee, reminding us that Santiam Hospital was an independent program with its own website and FB page and letting us know that his program's coordinator would not be attending future steering committee meetings.

Most managers would have understood what that letter meant, but Sharon acted as if nothing had happened.  A week later, she canceled the February steering committee meeting.  Two weeks later, the CEO sent another letter, this time spelling it out:  Salem Health was to remove all references to the Santiam Hospital program from its websiteSharon ordered the requested changes, but left the name unchanged, saying she wanted to take it to "the regional group."  It was only under continued pressure -- from the steering committee and from the resignation of her coordinator, who'd found a full-time position elsewhere -- that she finally relented and ordered the website and FB name changed to "West Marion County Service Integration." 

That was pretty much "it" for the steering committee.  Sharon said she was "resigning", but of course, it was her committee.  She reassigned one of her staff and hired a part-time contractor to cover the vacant coordinator position.  Then, in March, she persuaded one of the newer steering committee members (she was always dropping and adding members as suited her need) to call a meeting.  She was still wanting help finding someone who would take over her by now very messed up program.  Six weeks later, Sharon was no longer with Salem Health.  Two weeks after that, Salem Health announced to the teams that the program would be suspended for July and August while they conferred with "partners" about its future and that the teams should look for an announcement maybe mid- to late-August.    
So that's the very abbreviated story.  Plenty of folks are not going to like this account, but they need to remember, it's meant to be an object lesson on the danger of shortcuts to high-fidelity replication, not a sympathetic account of good intentions, or a comment on the teams or any of the unnamed participants.  It's not even a comment on the named participants, though it will seem like it to some.  Some will think it's wrong to call out anyone who's ostensibly trying to do good -- that it's "too negative", or somehow unfair.  They would have preferred a different story.  Fair enough.  They are welcome to tell that story and post it, or a link to it, in the comments section.  This happens to be a story about serious errors of judgment that affected CANDO and other communities and will continue to affect them, probably for a long time.  If we could have told it without specific reference to key figures, we would have.      

What makes this a particularly hard lesson is that most of the shortcuts were warned about.  Rolling out three teams at once.  Reassigning untrained, part-time staff, instead of getting the right person for the job.  Blowing off the funding guidelines and accounting practices.  Focusing on spending the money instead of working the problem.
Other mistakes were obvious -- including our own.  Not making sure everyone understood basic words and concepts before proceeding.  Not requiring partners to be committed (and honest).  Not attending to concerns raised by partners, especially those about the website.   

The big mistake, though, was failing to appreciate how hard it is to replicate a someone else's program.  Kevin Starr and Greg Coussa said it this way:

High-fidelity replication is hard.  You have to do everything as well as the innovators did. You can’t leave stuff out, make arbitrary changes to methods and procedures, or cut corners just because you didn’t raise enough money. If you do it wrong, it may not work at all. Replication is both a science and a high art: You must be committed to and obsessive about the details.

Epilogue:  In the fall of 2018, Salem Health announced it had "identified three new partners to help run and coordinate our teams."  With the exception of The Salvation Army, the "new partners" are the original pilot partners: Love, Inc. and the North Marion School District.  All are operating separate and apart from each other, and none claims to be attempting service integration.  For more on the Salem partners, see "TSA Launches Salem-Keizer Collaboration."

Wednesday, June 20, 2018

6/19/18 Minutes

Members: Deb Comini, Bill Thorp, Valorie Freeman  
Organizations: Denyc Boles, Salem Health; Misha O’Reilly, Cherriotts; Jayne Downing, Center for Hope and Safety; Dan Clem, Union Gospel Mission
City and County Representatives: Darron Mumey and Zach Merritt, Salem Police Department; Greg Walsh, Salem Emergency Manager; Jennifer Kellar and Toni Whitler, Salem Parks and Recreation Department;  Councilor Cara Kaser
Guests: none

The regular meeting of the CANDO Board of Directors was called to order at 6:00 p.m. on Tuesday, June 19, 2018, at the First Christian Church at 685 Marion Street NE, Salem.  The Chair and Secretary-Treasurer were present.

The minutes of the May meeting were approved unanimously.

Officers Mumey and Merritt of the Salem Downtown Enforcement Team reported car clouts were up with the warmer weather, especially in the parkades, and advised everyone to lock their cars, remove valuable items from sight, and keep their heads on a swivel.  They also reported increased fights and drug activity, specifically people smoking meth, in Marion Square Park, and said cameras would be a useful enforcement tool, especially as many of the people using the park are reluctant to call police when there’s a problem.  There are eight people currently enrolled in the new law enforcement assisted diversion (LEAD) program staffed by Josh Lair of the Marion County Health Department.

Councilor Kaser reported that the City Council had adopted the proposed 2018-2019 budget this week, with one minor modification, which added $50K to the transportation budget for Maple-Winter bikeway speed humps.  The sixth meeting of the Downtown Homeless Solutions Task Force, which has not been scheduled, will be to develop recommendations to the City Council.  The Congestion Relief Task Force has met three times and looked at some proposals by city engineers, but hasn’t decided anything.

In public comment, Greg Walsh reported that the City’s water quality had been below advisory levels for ten days, but the advisory would remain in place until at least June 27.  He then answered a number of questions, and took comments.  Misha O’Reilly spoke about the increase in pedestrian deaths in Oregon, and reminded everyone that every intersection is a crosswalk under Oregon law. Oregon Driver Manual.  Oregon Bicycle Manual.  

The board heard presentations by Toni Whitler and Jennifer Kellar about the status of CANDO’s parks and ways they might be improved, including installing bicycle fixit- and mutt mitt- stations at the Convention Center, and by Dan Clem about new policies at the Men’s Mission.

In the absence of a quorum, the Chair postponed new business to the July meeting, and adjourned the meeting at 7:17 p.m.

Friday, June 15, 2018

Sobering Thoughts

Revised: January 2019

By Sarah Owens and Michael Livingston

The City Council adopted the proposed 2018-2019 budget this week, with one minor modification, basically overriding  the Budget Committee and adding $50K to the transportation budget for Maple-Winter bikeway speed humps.

The new budget includes continued funding for HRAP and adds funding for the sobering center.  These are two of eight programs the City claims are "actively helping the homeless and working to reduce homelessness in Salem."  The other six are listed at left and on the City's website.

Mayor Peterson, bless her heart, could have offered up a similar list (less HRAP and the sobering center), but her politics got in the way.  She tended to view homelessness much the way she viewed addiction -- as moral failures to which a person should just say "no" and not the province of government except insofar as they threatened public safety.  Consequently, she did not claim credit for programs she might have, which gave the appearance the City "wasn't doing anything."

Mayor Bennett, ever the pragmatist, has no such qualms.  He also knows his constituents are very concerned about  homelessness, and his political legacy will depend in large part on his achievements in this area.  So, under Bennett, the City is both taking credit for its efforts in this area and attempting to do more, with programs like the sobering center and HRAP.

Although it is an extremely challenging program to run, HRAP is doing quite well, according to reports issued regularly by the Salem Housing Authority, who designed and runs the program.

The sobering center program, however, is something of a mystery, despite the budget commitment of $200K/year, beginning 2019.  Considering the sobering center wasn't funded in the 2017-2018 budget precisely because the City wasn't far enough along with the planning, this seems odd.

The last published staff report (issued about a year ago) stated, "As more details regarding specific roles, the site, and funding become available, staff will return to Council for consideration of budget, operational, lease and grant agreements."  Since then, few new details about the sobering center have been released, even to members of the Budget Committee.  Here's what we do know.

The latest budget says the project will be managed by the City Manager's Office (p. 202) and the Police Department will "lead the City's participation in this collaborative effort" (p. 239).

The Mayor's been heard to say that Bridgeway will operate the program (apparently having been selected without an RFP process), and it will be sited in the Mid Willamette Community Action Agency (MWVCAA)'s new building on Commercial Street (aka the ARCHES building), which is being "built out" for that purpose.  It's also been said that the legislature's committed funding of at least $300K.

The 2018-2019 budget doesn't specify what the $200K will pay for, other than "program costs", meaning operating costs, including rent. 

Book 1 of City's 2018-2019 Adopted Budget P. 239

Marion County's budget blurb indicates that the beds will not be for "alcohol-only sobering", as stated in the 2017 information report.

Marion Co. 2018-2019 Budget Committee Approved Budget

What will the sobering center try to do for drug- and alcohol-affected individuals?  The City says the sobering center will "connect individuals with treatment resources."  Marion County says it will "provide a path for addicted individuals to seek rehab services."  But how will the program do those things?  Will it be referral only?  Or will it be something more like Project Point?  What is being done to ensure treatment services will be readily available, so that there is not, as is currently the case, a long wait?  What measures will determine whether program methods are having the desired effect?  If the program's purpose is simply to "reduce the demand for needed emergency services and hospital beds" (Budget p. 4), do we know what the current demand is?  Or the target reduction? 
A sobering center is itself a "needed emergency service."  It's just a different kind of emergency service.  The assumption is that it's a less costly kind of emergency service, but is that really true from the City's perspective?

The City's 2018-2019 budget states that "there is not an offsetting revenue" for the sobering center, so it has to come out of working capital.  Salem Health, on the other hand, is paid to provide emergency services.  They also connect people with addiction problems to treatment.  How do we know it's going to be less costly overall to provide these services through a sobering center?  And how does it make sense for the City to take on its portion of the cost, whatever that is?

Overview National Sobering Collaborative
The National Sobering Collaborative is an organization formed couple of years ago to study sobering care as a national alternative model to current emergency department or police-based safety holding practices for intoxicated individuals.  It's preliminary survey of sobering facilities "suggests that sobering centers across the country are operating  without uniform or standardized practices, including triage protocols and outcome assessments."

Not one center studied billed insurance or individuals for sobering services, including billing of state-run Medicaid services.  The NSC considered that failure "surprising[,] given the potential healthcare savings these centers provide to Centers for Medicare and Medicaid Services (CMS) or private insurance companies."

At left is a portion of the NSC chart summarizing the survey responses.  Note that the San Francisco Sobering Center, with 11 beds and 4,450 encounters year, costs approximately $1M a year to run, and appears to sober the same folks roughly three times a year, with an average stay lasting between six and ten hours.

The 2017 information report suggests a Salem sobering center might encounter "as many as 20 a day" or "as many 300 a month."  Annualized, that's 3,600 to 7,000 a year, which is comparable to San Francisco's 4,450 (1,500 unique).  Why, then, does the City estimate it's only going to cost Salem only  $600K to $700K a year to run?  And how come Grants Pass is doing it for a lot less?   
Salem's sobering center was due to open in early 2019.  As of "early 2019", it's due to open in May or June.  Even though much of the community supports the idea of a sobering center, an idea is not a program.  HRAP is a program.  But, so far -- at least as far as the public is aware -- the sobering center is not much more than an idea with a lot of money behind it.

Last summer, the City Manager's Office had its hands fairly full with the water crisis.  There might not be enough "bandwidth" at City Hall to deal with that and constructing the new police station and developing the sobering center program in a transparent and inclusive manner.  There's also the question whether it still makes good financial and programmatic sense, assuming it ever did.

Sobering Ctr Design Drawing

There is a real danger that the City's efforts to deal with homelessness are fragmented, rather than comprehensive.  For instance, it is odd that the sobering center has hardly been mentioned during discussions of the Downtown Homeless Solutions Task Force (DHSTF) (fourth on the list at the top), which dissolved in August with a long list of recommendations (see here and here).

About 50 members of the public showed up for the DHSTF's hearing in June, with about 20 commenting.  Most of the comments, to the extent they touched on the proposed solutions, favored 4a (toilets) and 4d (showers and laundry) and opposed 4f (assess code), if that meant revisiting the sit-lie ordinance or something similar.  In the discussion that followed the comment period, no one even mentioned the sobering center or the ARCHES soon-to-open day shelter, or the new mobile shower/laundry program that United Way has been developing, suggesting they either didn't know about them, or didn't understand that those programs will directly impact the same areas they're concerned about.   If that's true, that should be very disturbing.

Piece meal will not get it.  The City simply must take a leadership role in developing a comprehensive approach to these problems.  During the Task Force meeting, Councilor Kaser indicated she felt that was not the City's responsibility.  The trouble is, everyone can say that, and when everyone says that, the responsibility devolves enforcement.  In other words, the City.

The police are, of course, just one part of City government.  But if residents prefer approaches to homelessness that don't involve law enforcement (which is what law enforcement also prefers), then the City simply must develop a shared and comprehensive approach to these problems.  We don't need more lists; we need leadership.  The City doesn't need to do it all, but it does need to convene and communicate.  In other words, to lead. 

1/23/19 Update:  It was revealed at the Council Policy Agenda work session on January 23, 2019 that the City's commitment to sobering center operating costs had risen from $200K to $250K.

Sunday, June 3, 2018

re "Assessing Codes and Ordinances"

June 13 Mtg Agenda
Motion:  (Sarah Owens) to oppose recommending that the City Council "assess codes and ordinances" as a "solution" to the problems of homelessness downtown (item 4.f. on the Downtown Homeless Solutions Task Force June 13 Meeting Agenda)

Discussion:  On June 13, the Task Force is scheduled to receive public comment on seven "proposed solutions" to the problems associated with homelessness downtown, one of which is to "assess codes and ordinances."

First, it must be understood that "assess codes and ordinances" is an indirect/politic way of saying the Council should revisit failed Ordinance Bill 22-17, aka the "sit-lie" ordinance, which they rejected last September 2017.  See here, here and here.   

Second, while there was general agreement among the Task Force members about the need for the other six "solutions" (all of which are intended to aid and assist people experiencing homelessness), there was not general agreement about the need for a "sit-lie" ordinance, although it was made clear to the Task Force that the Salem Police Department wants one, as does the Mayor.

Third, the "sit-lie" ordinance is not intended primarily to aid and assist people experiencing homelessness, but to be an "enforcement" mechanism -- a last resort -- in the event the other six "solutions" are insufficient to address the problems of homelessness downtown.  However, the other solutions will take time and trust for them to begin to make a difference.  If an enforcement tool is made available too early, it will be tempting to resort to enforcement too quickly, especially given how long the problems of homelessness downtown have been neglected, and that patience is, for some, in very short supply.  If that happens, it will likely undermine the trust-building strategy the Task Force seems to prefer.

Fourth, even if you think "assess codes and ordinances" is not meant to refer to revisiting failed Ordinance Bill 22-17, the City Attorney, Chief of Police and other city staff and elected officials have already assessed the code, and the result was Ordinance Bill 22-17, which failed to pass.  Unless the Task Force has something specific to recommend, there's no point.  Council can direct staff to "assess codes and ordinances" anytime they choose. 

Draft April 4 Minutes
Finally, the seven "proposed solutions" listed in the June 13 agenda were selected from a wide range  of "solutions" put before the Task Force during the course of four meetings and through "homework assignments."  However, we do not know who made the selection, or how.

At the Task Force's last meeting, it was agreed that staff were to "take solutions developed from prior meetings and homework assignments", do some research, and then bring that research back to the Task Force, who would then "formulate recommendations to City Council."  (See draft minutes of the April 4 meeting here.)

Since that meeting in April, the Task Force has not met, and so could not have selected the seven "proposed solutions" listed on the June 13 meeting agenda. 

Why does it matter who chose the seven, if they are only listed for purposes of facilitating public comment, and not the Task Force's final say on the matter?  It matters precisely because the list gives  the false impression that the Task Force believes there's a need to "assess codes and ordinances", thereby influencing public discussion and providing political cover for revisiting controversial  Ordinance Bill 22-17 when the "assessment" is completed.    

In sum, CANDO should oppose this "proposed solution" because it doesn't come from the Task Force, it isn't specific or straightforward in its purpose, and it's premature.  If and when the preferred strategy of relationship- and trust-building has been given a chance to make a difference, there appears to be a good faith need for a code enforcement mechanism, that will be the time for the City Council to "assess codes and ordinances."

For all the reasons discussed above, CANDO should oppose recommending that the City Council "assess codes and ordinances" as a "solution" to the problems of homelessness downtown (item 4.f. on the Downtown Homeless Solutions Task Force June 13 Meeting Agenda).

[6/22/18 Update: as shown by the minutes of CANDO's 6/19 meeting, this agenda item was postponed to the July meeting due to the absence of a quorum by the time the item was reached.  At the sixth meeting of the DHSTF, which as of this writing has not been scheduled, the DHSTF is supposed to develop its specific recommendations.  Based on the opposition to enforcement action expressed at the public hearing on June 13, it appears the task force might be unable to agree on a specific enforcement recommendation, in which case there would be no need for CANDO to take a position on the matter.]