FROM SILOS TO SYNERGY
The“ Big-Small Town” Strategy How We Can Bridge Louisville’ s Medical Silos
I by David E. Roth, MD
love working in small towns, where professional collaboration often feels more natural. Medical resources may be more limited, but we frequently provide excellent care because professionals who work“ in the system” and“ for the stakeholders” live alongside one another outside their professional roles. That web of relationships makes collaboration and warm handoffs seamless, and patients benefit. In bigger cities like Honolulu or Louisville, where more resources are available, it is often harder to bridge systems and align stakeholders. But it does not have to be this way. I want to share how, for a time, many of the largest stakeholders in Hawaii managed to work together as naturally as people do on the rural islands of Lanai and Kauai.
Hawaii is mostly a rural state, and historically, most of its mental health resources and providers were concentrated in Honolulu. On resource-impoverished rural islands like Kauai and Lanai, collaboration was both ubiquitous and necessary. Professionals and bureaucrats from major community stakeholders often worked in adjoining offices, shopped at the same grocery store or played in the same jazz band.
In Honolulu, by contrast, those same professionals sat safely entrenched in their silos. It took a federal court to compel the statewide Department of Education and Department of Health to collaborate on redesigning and deploying a process to identify and treat school-age children with mental health needs. In 1994, a federal consent decree settled a class action suit brought on behalf of Hawaii’ s children, after the state was found in violation of federal law for failing to provide mental health services to students who needed them. Under the Felix Consent Decree, named for Jennifer Felix, a Maui student with autism, the Department of Education and the Department of Health were placed under federal oversight and required to build a comprehensive system of care. I trained and practiced within that system in nearly every role: as a triple-boarded resident and fellow, as a subcontractor for agencies providing these services, as the owner of an agency contracted to provide them across the islands and as the Clinical Director of the Department of Health’ s Honolulu Branch.
From the inside, the system built during this collaboration worked for clinicians, educators, families and patients. The eligible population( continued on page 14) August 2026 13