Dr. Ken Minkoff on Value-Driven Systems Change

Dr. Ken Minkoff was recently interviewed for the Homelessness Resource Center newsletter.

Dr. Ken Minkoff is an expert on integrated treatment of individuals with co-occurring psychiatric and substance disorders. He shares his perspective on value-driven systems change and the development of integrated systems of care for co-occurring disorders. “We have to build the capacity to welcome, inspire, and address the needs of people and families with complexity into absolutely everything we do. Our work is about the needs and values of the people seeking service and the values of people delivering it,” says Ken.

“Behavioral health systems have historically been organized to see people and families with co-occurring mental health and substance use disorders – and other complex needs – as misfits. Providers are often organized to experience people as problems, not priorities. They might attach negative labels such as ‘antisocial, manipulative, borderline, non-compliant, medication-seeking sociopaths.’ People who experience co-occurring disorders are most likely to lose housing. This loss of stability is often connected to being “unwelcomed” in traditional housing and services programs. In one of our early projects, my partner, Dr. Christie A. Cline, and I discovered that there is a direct link between people with co-occurring disorders losing hope and dying because they give up,” says Ken Minkoff.
[pullquote]Our work is about the needs and values of the people seeking service and the values of people delivering it.[/pullquote]

Ken Minkoff is a board-certified psychiatrist who provides consultation to large public behavioral health systems. He helps them to build welcoming, resiliency- and recovery-oriented, integrated systems of care. These systems are designed to support both providers and people who live with co-occurring substance use and mental illness disorders.

Ken is one of the nation’s leading experts on integrated treatment of individuals with co-occurring psychiatric and substance disorders. He is also an expert on the development of integrated systems of care for people with co-occurring disorders. He focuses on the implementation of a national consensus best-practice model for systems design: the Comprehensive Continuous Integrated System of Care (CCISC). His passion for this work stems from his earliest interests in community psychiatry. He focuses on who needs services the most and who is least able to pay. His work explores how systems assume responsibility for people who have complex mental health, substance use issues, and accompanying health and social concerns.

Ken and his partner, Christie Cline, do not see systems transformation as an intellectual exercise. They believe that everything starts from the heart. The CCISC model recognizes that people who have the hardest time are those with the most complex needs. These individuals must be recognized as priorities for system-level attention. Their model emphasizes that it is the job of systems to welcome those who are most in need. As Ken says, “epidemiological and clinical service data suggest co-occurring disorders are an expectation, not an exception. This becomes the major driver for systems change.”

“Our job is to design systems within limited resources based on the needs, hopes, and dreams of the people coming in the door. We will never be successful at addressing the needs if we simply create special programs with extra resources we don’t have. We have to build the capacity to welcome, inspire, and address the needs of people and families with complexity into absolutely everything we do. This is the basic starting place of CCISC. The thing that drives this is building from the heart. Our work is about the needs and values of the people seeking service and the values of people delivering it,” says Ken.

His goal is for every single program, and every single person delivering care, in the entire behavioral health system, to engage in a process to become welcoming, recovery-oriented (hope-inspiring) and co-occurring-competent.

Ken recognizes that recovery creates a common language and philosophy for people who have mental health conditions, as well as substance use disorders. He sees that the language of recovery is starting to become much broader. People can be “in recovery” from a wide range of conditions and experiences, including trauma; primary health conditions; physical disabilities, cognitive disabilities, nicotine dependence, gambling; incarceration; homelessness; domestic violence, divorce; and loss. Ken believes the role of community mental health and substance abuse providers is to inspire people to engage in partnerships to make progress in addressing all their conditions to achieve the hope of recovery and to build momentum towards a happy, productive, and meaningful life based on their own goals.

“This is inspiring to people. Many people go into behavioral health care because they want to help people and because they act from their hearts,” says Ken, “but then find themselves caught up in systems and practices that make it hard for them to act in accordance with those values.” That is why he believes the system has to take on the biggest possible vision of hope. In his work, every program and every person is guided to be welcoming, recovery- and resiliency-oriented and co-occurring-capable. Agencies that are co-occurring-capable are organized within their existing framework and mission to deliver integrated, matched best practices, and interventions for multiple issues to support individuals and families with complex needs who are coming to the door.

“Recovery is a process that involves moving through stages of change. There are parallel processes of recovery for multiple diseases and conditions,” says Ken. “It is about the person. That is why we use a common language that applies to multiple chronic, relapsing disorders or conditions. Recovery is not recovery “from” a condition, but recovery of the human being who has one or more conditions. A person with one or more relapsing conditions can recover pride, self-worth, hope, and dignity, moving beyond stigma and disability, even though the conditions, disability, and risk of relapse may persist.”

Ken believes in the fundamental principle of creating a welcoming system. It transcends the concept of a “nice idea.” He challenges agencies to ask themselves: to what extent have we organized our programs at every level – in policy, procedure, and practice – to be proactively and purposefully welcoming? Are we welcoming to individuals or families who may feel to us that they do not “fit well” into what we offer?

“Large systems are often like nesting Russian dolls that are not actually quite so nesting, with multiple ‘systems within systems’ sitting next to other ‘systems within systems.’ Our goal is to have all those systems and subsystems moving in the same direction. We want all parts of the system to work on being welcoming, recovery-oriented, and co-occurring-capable. We have tools to help each program to organize and create improvements. We teach systems to charter the improvements as a collective quality improvement partnership, within the budgetary resources they already have,” says Ken.

Quality improvement concepts for business systems include partnerships across vertical and horizontal domains. It includes companies and customers. Ken cites the National Improvement of Access to Treatment (NIATX) as another project that builds on the concept. “In our work, Chris and I have helped systems to identify thousands of change agents who represent the voice of front-line clinicians and clients in the system. We help organize a change process in which those change agents are empowered individually and collectively to work in partnership with leadership to transform the established order of the system.”

All improvements are built in relationship to the value of welcoming and inspiring the individuals and families who have the most complex needs who need us the most. “It has been so much fun to see people get inspired and have a chance to come together, and see the results in a sustainable change process that shifts the entire culture of a system. It has a real impact on the delivery of care,” says Ken.

If the mission of an organization is to provide hope, then the value of hope must be replicated at every level. A useful metaphor for this kind of value-driven systems thinking is the image of a fractal. Fractals, which appear in nature, are natural objects like snowflakes and ferns, objects in which the smaller parts replicate copies of the whole object.

Ken offers the example of the intake assessment form. “There has to be a direct connection between the bureaucracy and the vision. Often, the intake chart will document 30 pages of “hope-sucking” deficits, and one small paragraph of something called “strengths.” Hope and strength should be the most prominent features on the chart,” says Ken. He suggests incorporating questions like, “What is your vision of a happy life? Describe a period of time in which you did relatively well in the face of all your challenges, and how you managed to do that?”

Ken and Chris support state and local systems in over thirty states, engaging consumers, families, clinicians, administrators, and state or county leaders at every level to improve their own systems. The CCISC model encourages recovery for dysfunctional systems of care. Ken and Chris believe that behavioral health systems should never settle for less. Rather, they must constantly strive for the goal of organizing everything they do, at every level, to be about the needs, hopes, goals, and dreams, of the people and families who come in the door in search of partnership and wellness.

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