Planning, Targeting, and Coordinating Interventions that will be Implemented in the Swampy Lowlands of Practice

Watch and listen as David Osher, Vice President and Institute Fellow (formerly Co-Director of the Human and Social Development Program) at the American Institutes for Research (AIR), discusses planning and implementing multiple interventions including considerations for community needs, organizational capacity, target population needs, and determining which individuals in a community receive which intervention, or which part of an intervention.

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Transcript

 “In the very topography of professional practice, there’s a high, hard ground where practitioners can make effective use of research-based theory and technique.  And there is a swampy lowland where situations are confusing messes, incapable of technical solution.”

Donald Schön wrote that in 1983, talking about reflective practice.  I think on the one hand, I’m a little more optimistic about the fact that we can handle some of the things he’s talking about, in part because we’ve done good work over the last 20 years in the areas of implementation science, in order to better understand it.  But when we put our little feet into the water, as Paul said, let’s remember that we really are putting our feet into places that already have lives – rich lives, where all sorts of things are going on.

What I’m going to try to do today is really tee up both this panel, but also tomorrow’s panel, because the issues really are connected.  And I want to draw upon – [indistinct] – science and practice-based knowledge to help us improve outcomes for diverse individuals in diverse swamps.  Because even when it’s easy, it’s still pretty tough.

I want to look first at place-based efforts and the needs to address the multiple perspectives of people in place-based efforts, then to discuss the challenges to coordinating and targeting efforts.  And then I’ll invite just suggesting some ways that we can think differently about intervention.

Ajay has already mentioned some examples of current work that’s going on in HHS.  I want to remind us of other things that are place-based and focused at a federal level, among others, are Systems of Care, Safe Schools, Healthy Students; Project Launch; Promise Neighborhoods.  And if we look at a local level, often with public-private funding, we can look at Strive, Say Yes to Education, Ready by 21, Blue Sky.  These are just examples, but are places that we can both learn from, in terms of what can be done.  We can also learn from about how tough it is to do it.

Now, there is some expected benefits of place-based efforts, and as I go, you can think about whether we’re realizing them or not.  To reduce fragmentation, we know that children and youth and families often require services for multiple families and need supports across multiple demands, particularly those who are at great levels of risk.  And oftentimes they don’t get it.  They fall between cracks, or they’re burdened by issues that really affect access and outcomes.

You know, for example, instead of being engaged in different ways, often what may happen is that people may go through multiple intakes, that they don’t find to be very, very helpful, and then they drop out of treatment.  And at the same time, when people are getting services from multiple places, there are opportunities for engagement that are sometimes dropped.

Another goal is to reduce costs.  That was a goal when Systems of Care were conceptualized in 1980s.  It’s particularly a concern right now, given what exists in terms of public and private finance.  They need to eliminate redundant and inconsistent services.

A colleague of mine, a school psychologist, once discovered that the same young woman was receiving pull-out counseling from four different people in the school, giving her different messages, and she was falling further and further behind, and she missed academics.

And at the same time, the goal is to build enhanced capacity to really address local needs.  For example, building social capital, and to develop a shared local accountability for our citizens, for our community members – all of them.

Now, among the challenges is whose needs are we addressing?  Is it individual needs?  Are they social needs, or are they both?  And depending on who’s at the table, we may have to say, “Both.”  Are there agency needs, or community needs, or both?  I tend to think we want to focus on community needs, but I’d suggest that without thinking about agency needs, you’re not going to engage them in a full way.

Is there one set of community needs, or are there many?  There’s some that are contested, and there are also subsets of needs.  We know from research in Chicago how, in the same neighborhood, you can find people who experience things in very, very different ways.  And those of us who are parents know that in our little families, there are micro environments.

Now, a challenge, I think, is to really address that multiplicity of perspectives and think about, whose problem are we addressing?  Because people may define it differently.  Those of us in sociology may remember C. Wright Mills talking about, “What is a social problem?”  Whose timeline?  That person going into an intake may have a real short timeline in terms of when are they going to get results?  That may be different than the economists.  Whose opportunity costs?

You know, those of you who read Tally’s Corner 30 to 40 years ago may remember that Tally does not follow the truck with the job because of the fact that he went through his own assessment of what the opportunity cost is.  Whose Return on Investment?  As you hear today and tomorrow from John, and Brian Yates tomorrow, we know that there may be a multiplicity of Return of Investments, depending on whose making them.  In other words, whose bottom line?

So, why is definition of need important?  One is because we want participation – participant buy-in, their engagement and voice.  And participants include the end users; it also includes the implementers.  It probably also includes the bosses and who they’re accountable to.

Help in selecting interventions.  And adapting, if necessary and possible, the interventions.  For example, if we think about family-driven and youth-driven work, what happens when we don’t ask a caregiver who is expected to do something, whether or not they’ll be available to do it?

What happens when you have this great technology that can work for a young person who has assistive-technology need, but you don’t ask that young person whether or not they will wear it?  What happens is that you have a great intervention that doesn’t work.  We need their help in monitoring interventions, because they are at the point of the problem.

Community engagement is also important, both the community coming to judgment so that it weighs alternatives, but to continue to sustain efforts that cost money as other challenges arrive.  And we need to get all the voices because equity is huge, and there are lots of people in our society who are marginalized and who are silenced.  And if we’re going to really address equity in terms of access and design, we need their voices.

So, how do we coordinate and target efforts?  Part of the challenge is that there are, as you know, competing missions and authorizations, competing constituencies that pull organizations at the local level in different directions.  Competing cultures, priorities, indicators that often come from the federal government that are competing, that people are accountable for.

What we also need, if we want to help people work, is to help them develop trust, to develop a sense of collective efficacy and shared accountability, where I am responsible, but we together are responsible.

As you may know, the draft National Plan for Youth is now out on findyouthinfo.gov.  And in the process of developing that, we did listening sessions across the country for the federal Interagency Working Group on Youth Programs.  And what we heard again and again is people don’t know everything, or even enough about what’s going on in their community.

But perhaps more importantly, as you think about procurements, and I know this also requires going to general counsel and things like that, if you give people one month to respond, you’re not going to find a deep, new collaboration because they’re gonna go to the usual suspects.  And at the same time, what they kept on saying is, “Give us common metrics so that we can really work together and be accountable together.”

So, how can we coordinate and target efforts?  One of the things is we need to operationalize and coordinate what we do at all levels.  Thinking about the child, the family, or the group that we’re intervening.  Thinking about what the line practitioner does.  Thinking about what her or his supervisor does.  Thinking about the director in the office.  Thinking about the broader office or school or district.  Thinking about the system.  And often times, what happens in collaboration is it’s not aligned; and when it’s not aligned, it’s not robust and often falls apart.

We also have to really make sure that national policy language and how things are evaluated work together.  I mean the evaluations at the Safe Schools, Healthy Students initiatives enabled people who responded to three grants to apply to one set of evaluation criteria, for example.  The Interagency Working Group on Youth developed a common definition of youth development.  That helps collaboration.

So, how can we coordinate and target efforts?  We have some lessons that come from what I’d say are insufficiently operationalized efforts.  There’s a failure to develop and monitor interventions.  We can come together; we can identify our problem.  I’ve never understood what a Kumbaya moment is, but we can really feel good that we’re responding.  But then we’re not going to do anything.  There’s a half-life, and we’re not going to follow up.

We need to be able to align the collaboration at all levels.  So, it’s not only work down amongst, in one system, but makes sure that supervisors across systems talk to each other, for example.

We need to also align promotion, prevention, early intervention, and treatment.  But oftentimes we see these as different.  Oftentimes we fund these as different.  But if you think about a family, if you think about a community, they all connect.

We also have to address the lack of public transparency regarding needs outcomes – I should say needs, outputs, and outcomes.  And that’s important, in part, to build will; it’s important to sustain will.  It’s also important to address what happens across the country when the new person comes in on her/his white horse and changes the game.  And what we know is, that person is then muddying and muddling in very confused waters that he or she will also confuse.  Public transparency can help us address that.

What can be done to promote collaboration?  We need processes to develop effective partnership amongst stakeholders, high levels of trust and communication, shared vision and values between and among service providers and other stakeholders, planning and coordinating mechanisms, to respond to community needs.  And remember, better define what the community is; it’s not that simple.  To jointly plan, deliver, monitor, and evaluate interventions and services.

I’d also say if want to do it, we have to focus on the highest common factor, not the lowest common denominator.  And that means focusing on the needs of the end users, but it also means focusing on the constraints and needs of the doers.  The logic of – I used to think that we’d get good collaboration by everybody funding the same pool.  I think braiding works a lot better because it forces people and enables people to talk about their needs and constraints. There has to be a common goal, but you have to address the constraints that people have. 

And, as you’ve heard before, we need common indicators.  And we need to be able to develop and have aligned performance metrics.  County leaders, city leaders, in a system like education, school leaders are not going to work together if they’re not accountable to work together.

In some of my work, we’ve been able to use dashboards to really promote collaboration, both at a formative level, where it can reach down to the client level, but sum up to the community and system level.  Contain everyone’s key indicators with the ability to disaggregate, and to provide timely data for improvement.  And at the same time, while that should be happening in a timely manner, we need some way of summing up annually, in a transparent way for the public, which can be done in ways that are aligned to individuals’ and agencies’ performance metrics.

Now, a little more on targeting interventions.  We have systems to effectively use risk and protection data, as well as data on assets, for example, Community of Care, Getting to Outcomes, PROSPER.  But oftentimes, as designs are used, they don’t address crossover and sleeper effects.  They often don’t address the interdependence of interventions.  And whether we intend it or not, there are multiple interventions taking place that are likely to affect outcomes.  Ajay talked about this.

How do interventions with members of a family, a school class, the entire school, or community affect other members?  Take, for example, what happens when you develop one individual’s ability to regulate her/his emotion?  How do interventions by one agency, or in a community, affect the outcomes or interventions by other agencies in a community?

That’s what Ajay was talking about.  And one of the things I see in my work is people keep on talking about intervention fatigue, too many things.  These unanticipated consequences can and, to some extent, can be anticipated or addressed.

In terms of selecting all providers, all organizations are not equal.  There’s a difference.  They may vary in terms of organizational culture and leadership.  The conditions for performance, growth, and collaboration.  For example, does staff feel safe?  Their commitment to transparency.  Their commitment to capacity for cultural and linguistic competence.  Their ability to provide clinical supervision, and to support reflection and deep learning.  And the capacity to establish positive relationships with their clients, with families, and with other agencies, and to use data for continuous improvement.

And finally, I think current models may not sufficiently address the possibilities for and challenges to community interventions: how to combine promotion, prevention, early intervention, and treatment; how to address variation of impact that always exists; how to address the social and ecological validity needs, concerns of practitioners and participants, including thinking about community-defined evidence.  And addressing what Donald Schön, in another article, talked about: the “indeterminate zones.”  And what Michael Huberman, thinking about a teacher, talked about “busy kitchens.”  Many things going on that are marked by uncertainty, complexity, and multiple demands.

Do I have any more time, or I think I’m done?  So, I think that is fine.  You can read the rest later, and I thank you.

[Applause]