FROM SILOS TO SYNERGY
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grew roughly fourfold in the system’ s first five years, from about 2,900 children to nearly 12,000. 1 By the time the decree ended in the mid- 2000s, the system was reaching many times the youth it had served at the start, and reaching them well. I could move a child to a higher or lower level of care and collaborate easily with providers at each step, because we were all accountable to the same plan.
In our Individualized Education Program meetings, the needs of the most challenging children were met because schools received clinical support and cost-sharing from the Department of Health, and the Department of Health gained the schools’ daily knowledge of the child in return. It was sometimes grudging and rarely perfect. But it happened.
The state’ s Juvenile Justice and Child Welfare departments joined voluntarily, sitting down with us in multisystem meetings to untangle the most complex cases. In my various roles, I was in those rooms and saw firsthand how well this collaboration worked. I watched agencies that had every institutional reason to remain separate behave, for a while, like a single team surrounding one child and family. At times, it felt like we were working together on Lanai. We developed a web of relationships and friendships that extended well beyond our professional roles.
Then, the mandate was lifted. Hawaii reached substantial compliance in 2002, and the decree was terminated in 2004. As federal oversight receded, so did the collaboration. Agencies drifted back toward their separate lanes, and the seams we had worked so hard to close slowly reopened. Many of my friends and colleagues left their system roles as organizations downsized. When we saw each other socially or at a conference, we grieved the loss of that special time in our careers, when we knew each other and could pick up the phone when a patient, client, student or foster child needed help.
That is the lesson I most want to share with my new colleagues in Louisville, because it is the uncomfortable one: the collaboration was real and effective, but it required external pressure to both initiate and sustain it. The moment that pressure was gone, the collaboration broke down and the silos rebuilt their bureaucratic walls. Which raises this question: how do we build small-town-style collaboration that lasts when no one is enforcing it?
Each of us has the power to foster connection as we do our clinical work. As we open our new interventional psychiatry clinic, Bluegrass Advanced Mental Health, we are intentionally reaching out to our community stakeholders and to our colleagues in other specialties and levels of care. We recognize that our potential patients are currently treated in silos defined by level of care, payer, age, professional training and medical specialty. We want to make our interventional treatments accessible across the Louisville medical system, including Spravato( esketamine) for treatment-resistant depression and Transcranial Magnetic Stimulation for major depressive disorder, anxious depression and obsessive-compulsive disorder. In the coming months, we will reach out to primary care practices, both adult and pediatric, where most patients first express concern, and to the APRNs, psychiatrists, psychologists and social workers who provide traditional mental healthcare. We want OB-GYN practices and school counselors, who often identify distress before anyone else, to be aware of these treatments. And we want to build relationships with our colleagues in intensive levels of care( emergency departments, urgent care centers, inpatient psychiatric units and residential programs) so they feel comfortable calling us to arrange a warm handoff. Like our colleagues in Kentucky’ s small towns, and the families I worked with in Kauai, we look forward to knowing your name, recognizing you at the grocery store and standing ready to answer your calls for help or advice.
Hawaii showed me both halves of the truth. Collaboration across specialties and institutions is not a slogan; it demonstrably improves care and serves far more people than fragmented systems ever will. But it also showed me that collaboration is fragile. Waiting for an outside force to compel it is a poor strategy, because that force can leave with the changing administrative climate. We can do better than that. Each of us can decide to build these connections on purpose, strengthen our community and create a relationship-based community of care for our patients.
The Louisville medical community has the potential to be more like Kauai than Honolulu. We do not need a federal consent decree to make us better. We just need to make the extra effort to build relationships outside of our silos and create opportunities for collaboration in our big-small town. Reference
1
Hawaii State Legislature, S. C. R. No. 65, H. D. 1( 2001). The resolution documents Felix class growth from an estimated 2,894 children in 1994 – 1995 to 11,842 in
1999 – 2000. capitol. hawaii. gov.
Dr. Roth is the President and Chief Medical Officer of Bluegrass Advanced Mental Health, LLC.
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