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Future Search in the Context of Public Health: The Wisconsin Story Introduction Milwaukee, Wisconsin, USA, 2000: Milwaukee, Wisconsin, like many other cities in the United States, has experienced multifaceted changes during the past 40 years that have profoundly affected the health and safety of its citizens. The changes include the emergence of Medicaid Managed Care in 1984 and of welfare reform in the mid-1990's. At the same time, racial and ethnic disparities in health indicators such as infant mortality worsened, and the sense of exclusion felt by the city's long disenfranchised population intensified. In 1993, a small group representing central city hospitals, public health, community advocates, family members, and foundations started to consider the feasibility of applying future search to the reduction of infant mortality. These initial deliberations resulted in Milwaukee Common Ground. Also in 1993, the Wisconsin Maternal and Child Health (Title V) Program, housed within the state's Department of Health and Family Services in Madison, established Five Guiding Principles as the driving force for its endeavors to enhance the health and safety of all children and families. The future search principles being applied through Milwaukee Common Ground and the Five Guiding Principles being implemented throughout the state turned out to be remarkably congruent. This paper is the story of that congruence. Milwaukee Common Ground Common Ground includes stakeholders from medicine, managed care, public health, foundations, education, clergy, community leaders, government officials, welfare reform, and families. The specific focus is on fostering collaborative efforts for the reduction of infant mortality. Milwaukee Common Ground sponsored future search conferences in 1994, 1995, and 2000 to strengthen the ties among the above stakeholders with the goal of reducing the city's high infant mortality, which disproportionately affects families of color. At the initial conference in 1994, the group of 50 participants at the Wingspread Conference Center in Racine discovered first steps toward unity and respect and started to overcome some of the turfdom and walls that had divided them from each other. One issue that emerged at the initial future search in 1994 were deeply divisive feelings of alienation based on race. Common Ground's efforts intensified after the first conference when many participants experienced a growing urgency to include families in all phases of infant mortality reduction efforts and other public health efforts. Unusually candid discussions at follow up meetings in May and October of 1994 brought to light the enormous challenges faced by systemic factors of racial discrimination. To this day, Common Ground remains as one of the only forums at which people feel relatively safe in discussing such a sensitive and divisive issue. Notable features of the second future search in 1995 were the inclusion of youth, the public school system, and religious leaders as stakeholders; Spanish and Hmong interpreters; and enhanced efforts for on site childcare and transportation to support the involvement of families in the process. "It told me," said one parent, "that they [the organizers] really wanted parents and community members involved. I had experienced many health professionals as cold and insensitive. At the conference I met many people who do care." In addition, the four facilitators of the second future search included a community leader and a single father. All had taken part in a Future Search Learning Workshop led by Marvin Weisbord and Sandra Janoff. Reshaping systems and building healthier communities through future search takes time and the commitment to make find long-term change. If all stakeholders of a community are to have an impact on the systems and associations that affect the health of their children, people and organizations need to learn how to incorporate future search principles into their work and service. After the second future search in 1995, Milwaukee Common Ground became an ongoing effort to discover, sustain, support, and celebrate a diversity of strategies and forums to keep the future search spirit alive. In 1998, the Milwaukee Healthy Beginnings Project, funded under the federal Healthy Start Program, decided to staff and coordinate Common Ground and sponsor the third future search conference in 2000. The grantee for Milwaukee Healthy Beginnings is the Black Health Coalition of Wisconsin, a community-based agency that prides itself in family involvement and inclusion as the foundation for all that it does. This investment in Common Ground by Milwaukee Healthy Beginnings provided evidence of the potential for future search to have long-term systemic ripples. The third future search conference in June 2000 was facilitated by two of the 1995 facilitators as well as a staff member from Healthy Beginnings and a 21 year old mother from the community, both of whom had attended the Future Search Learning Workshop just two months earlier. The third future search was characterized by the infusion of many people new to Common Ground, a remarkable translation service that enabled the Hispanic stakeholders to play a larger role, and a level of harmony that represented a significant contrast from the first future search 6 years earlier. The outcomes of Common Ground have been multifaceted. They include the following:
In summary, future search has started a process that has the courage to tackle the thorny systemic issues that are root factors contributing to many of our health disparities and health access shortcomings in the United States. It has equipped about 200 people in Milwaukee with the tools necessary for profound systemic change. The incredibly rich personal stories that our participants share serve to heighten our sensitivity and, ultimately, our commitment to achieve social justice and peace. We also constantly remind ourselves that every experience provides us with a new opportunity to learn and grow. We often quote Rev. Martin Luther King, Jr., when he said that "We must learn to live together as brothers and sisters, or we shall perish together as fools". Many of us want to do what is best and are trying, but we have to understand how people of color, under the accumulative weight of centuries of being marginalized and oppressed, rightly are suspicious. Trust is always fragile, but the future search ripples in Wisconsin have led us in a path that, although less traveled, enables trust to stand on firmer ground. The Five Guiding Principles In 1993, the same year that Milwaukee Common Ground started, the Wisconsin Maternal and Child Health (MCH) Program established Five Guiding Principles: family-centered care, community-wide leadership, resiliency, outreach, and cultural competence. The principles reflect an underlying belief in the central role of communities and systems in supporting children and families and in affirming the core human values of dignity and respect as cornerstones for their health. This means that the essence of MCH lies not only in the prevention and reduction of morbidity, mortality, and risk but also in the fostering of the potential of children and families to become compassionate, productive, and dignified citizens of their communities and of society as a whole. The overarching purpose of these Guiding Principles is to define the culture of maternal and child health services in Wisconsin so that both providers and recipients of services engage in partnerships to enable them to tackle the difficult issues that affect all of us. We believe that the path to achieving Healthy People 2010 objectives involves building community investment in child and family health by putting into practice the Guiding Principles. The Five Guiding Principles To enhance its efforts to achieve public health objectives for 2000, the Wisconsin Division of Public Health launched in 1992 an 18-month planning process. The purpose of the process was to plan for the allocation of federal MCH Block Grant funds from the state Title V agency to local and statewide projects for a five-year cycle from 1994 through 1999. The process included in-depth internal and external dialogue involving a wide array of staff members throughout the Department of Health and Family Services, the Maternal and Child Health Program Advisory Committee that had recently added consumers, and broad-based public input through Regional Town Meetings. During the planning process, the Five Guiding Principles emerged as themes to be applied to all MCH activities in Wisconsin. These principles represented a change in priority from primarily funding direct MCH services to funding projects that address MCH systems and policies in all of their complexity and potential for change. The emphasis changed from relying primarily on the MCH Block Grant to being able to draw on multiple other funding sources and to view child and family health within an interlinked ecological context. The interlinked ecological context refers to the role of caring human relationships, social support networks, and a sense of community in promoting better health and developmental outcomes. The benefits that result from positive social connectedness include stronger resistance to infectious disease and greater protection from the stress of poverty as well as the risk for abuse. Site Visit In November 1993, a Federal MCH Team Site Visit to Wisconsin took place at the request of the Division of Public Health to the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA). It was the first statewide site visit of its kind in the nation with its emphasis on systems development rather than a traditional MCH program overview. The 22-member Site Visit Team, led by the MCH Bureau, was comprised of representatives from several branches of the federal government - the Health Care Financing Administration, Administration of Children and Families, Centers for Disease Control and Prevention, the Social Security Administration, HRSA's Bureau of Primary Care, and the Department of Agriculture. They formed a unique partnership for this consultation in collaboration with nine other consultants chosen for their expertise in family-centered care, community organization, and integration of services at the local and state level. In addition, Federal amendments to Title V in 1989 (OBRA 89) and the start-up of prenatal care coordination, a package of non-medical psychosocial support services, as a Medicaid reimbursable benefit in 1993 led us on to a path that approached MCH from a systems development and community perspective. Systems Approach Underlying the systems approach is a much more comprehensive view of health to encompass not only physical and mental but also social, spiritual, and community well being. The systems approach, affirmed by the Site Visit and the Medicaid prenatal care coordination benefit, led to our efforts for holding Title V Block Grant funded agencies accountable for developing family-centered and culturally competent practices that engage families as partners and respect the diversity of cultures and traditions in Wisconsin. It also meant an increased emphasis on leadership development at the community, regional, and state levels. We recognized that effective outreach is integral to all MCH efforts. And we defined outcome-driven analysis as a more effective source of information for evaluating our efforts than process measures. Moving toward the achievement of the Five Guiding Principles means giving all people a voice in the systems and forces that affect their health and safety. They call for a transformation in the way we practice public health. Our health care systems are not structured to allow for the inclusive process that is central to these Guiding Principles. For example, we need to engage non-traditional stakeholders from the business, religious, and non-profit sectors. We need to make special efforts to welcome and include families and community leaders in all phases of designing, implementing, and evaluating health care systems and practices. Implementing the Principles Through a Request for Proposals process in 1994, that featured the Guiding Principles among the selection criteria, the Division of Public Health awarded Title V MCH funds to 133 agencies, including several new projects. An example of a new project was the Children's Health Alliance of Wisconsin, a statewide organization that has taken on the issue of inadequate oral health care access for low-income families. It has sustained itself as an autonomous organization no longer fully dependent on the MCH Block Grant by acquiring support from other funders such as the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation. The Five Guiding Principles have had a far-reaching influence on MCH work in Wisconsin, not just on MCH Block Grant funded programs. In 1999, we incorporated the Guiding Principles into several Requests for Proposals for statewide Title V projects funded under the new Block Grant cycle starting in January 2000. We did this by giving the Guiding Principles significant weight in the criteria for scoring proposals and by selecting a diverse group of reviewers who believe in their importance. As part of the start-up of our new Title V funding cycle in January 2000, we have also incorporated the Guiding Principles into contracts and work plans with local public health departments, community based organizations, and medical centers. We also coordinated with other agencies in state government so that the principles became incorporated into special projects such as the establishment of Child Care Centers of Excellence to meet the growing demand for child care as a result of welfare reform. Organizational Self-Assessment As of January 2000, after a planning process similar to the one used in the early 1990's, all MCH Block Grant funded agencies are required to conduct at six month intervals a self-assessment of the extent to which they incorporate the Five Guiding Principles into their own organizational culture. This self-assessment tool represents a major achievement in making the Guiding Principles practical and relevant in the practice of maternal and child health in Wisconsin. This MCH Block Grant application for the federal fiscal year 2001 goes beyond the needs assessment as required by Title V. It contains a section describing the strengths and capacity of communities in responding to these needs. Maternal and Child Health Program staff identified these resources by conducting interviews with all local public health and tribal health department directors. The directors provided qualitative data on the strengths and assets of their communities. Other Efforts The Five Guiding Principles have influenced numerous MCH initiatives not funded under Title V. For example, a 1994 report, Building Bridges to Reduce Perinatal Substance Abuse, released by the Wisconsin Maternal and Child Health Coalition, a statewide advocacy group, gave specific recommendations for incorporating the Five Guiding Principles into all programs that address perinatal substance abuse. The Wisconsin Plan to Prevent Adolescent Pregnancy, submitted to Governor Tommy Thompson from the Departments of Workforce Development and Health and Family Services in 1998, represented the work of dozens of citizens from all walks of life. This plan adopted the Five Guiding Principles and stated that "all programs (and) efforts relating to (the) plan…need to apply these principles." 5 A 1997 statute authorized the Department of Health and Family Services to establish Prevention of Child Abuse and Neglect Projects throughout the state. The Department integrated the Guiding Principles into the design, implementation, and evaluation of these projects. For example, a major component of this effort during its first year was to develop a curriculum for home visitors and their supervisors. The University of Wisconsin Extension, which provides educational programs to citizens in all 72 counties of the state, included the Five Guiding Principles in its courses offered to project staff. It taught 160 participants in 1999. Overview of Principles and Examples of Implementation A brief description of each principle and specific examples of its implementation follow: 1. Family Centered Care - The core principles of family-centered care, as described by the Institute for Family-Centered Care (a nonprofit organization that provides leadership to advance the understanding and practice of family-centered care), are the following:
To recognize and respect the expertise of families as policy and program advisors, the Wisconsin Division of Public Health expanded and diversified the membership of its MCH Program Advisory Committee in 1992 to include families who receive MCH services. Reimbursement for travel and childcare and a concerted effort to eliminate jargon and acronyms from written and verbal communication have created a forum in which family members feel that they have a legitimate voice. In 1999, the 45-member committee, six of whom are family members, elected a parent of a child with special needs as its Vice-Chair. A second example of our efforts to strengthen family-centered care involves the two federally funded Healthy Start Projects - the Milwaukee Healthy Beginnings Project, for which the Black Health Coalition is the grantee, and the Honoring Our Children with a Healthy Start project of the Great Lakes Intertribal Council for the Native American population. See Section 1.5.2 for a description of these efforts. 2. Community Wide Leadership - The letters, MCH, stand not only for Maternal and Child Health. They also stand for Making Community Happen, a process that is central to Wisconsin's vision of a more inclusive and equitable system of health care for children and families. We have widely promoted the use of MCH as a symbol for making community happen to raise awareness of the connection between healthy communities and healthy children and families. This principle requires a long-term commitment of time, energy, and resources, involving risk taking, on the part of public health providers, planners, and administrators. A key component of an effective MCH program is its ability to bring people together from many sectors of a community. The community wide leadership principle goes further, recognizing all people as experts and giving people a voice in the systems that affect their lives. An example of community-wide leadership is Milwaukee Common Ground. See Section 1.5.2 for details. The Common Ground effort - with ongoing leadership from the Wisconsin MCH Program - includes physicians, managed care executives, and public health leaders and practitioners; people from foundations, academia, and business; and clergy, community leaders, government officials, welfare workers, and families. 3. Resiliency - The Guiding Principle of resiliency refers to the capacity of children, families, neighborhoods, and communities to "bounce back" in spite of stressful circumstances. The principle of resiliency builds on strengths within the individual, family, community, and society. Historically, public health services have had a focus on deficits, risks, pathology, and disease. When we engage the people that we serve in family-centered dialogue through Common Ground and other forums, we hear traditional areas of need identified, such as child care, transportation, fragmented and hard to figure out systems, and limited hours of access. But we also hear families openly discuss the pain caused by systemic and long standing injustice - biases resulting from issues related to social class, race, and gender, layered on top of the burdens of living in poverty and in abusive and neglectful environments that cut across socioeconomic lines. The plea that we hear, and that we strive to honor in Wisconsin's Title V Program, is for more respect for the dignity and skill with which most families survive and thrive, in spite of often overwhelming stress. Most of them do a lot better than we may rush to judge. People do not want to be primarily viewed with stereotyped labels such as "unwed mothers", or as sets of risk factors, morbidity, and mortality that require public health solutions. This approach does not exclude traditional medical and public health models of risk identification and reduction of morbidity and mortality, but goes beyond them. It strives to foster patterns of behavior that enhance the quality of life in areas such as communication skills, positive decision making, and self-esteem. The important questions become: Why do some children grow up in chaotic and sometimes violent families and communities with success, while others end up failing in school, engaging in violent behavior, and abusing drugs? Why do some children "beat the odds" in difficult situations, while others get trapped into self-destructive behaviors? An example of a resiliency-based program in Wisconsin is the African American Infant Mortality Resiliency Project. See Section 3.1.2.1 for details. 4. Outreach - This Guiding Principle turned out to be timely in light of federal welfare reform legislation in 1996, which separated the requirement for employment from Medicaid eligibility, and the initiation of Wisconsin's welfare reform in 1997. An overarching lesson in states' early experience with the Children's Health Insurance Program (BadgerCare in Wisconsin) is the vital importance of effective outreach. The ability to obtain health insurance does not necessarily correlate with an individual's engagement with a health care provider, let alone one who gives family-centered and culturally competent care. Legislation, no matter how well intended, to broaden access to health care for America's children is not enough. A coordinated campaign to communicate availability of these benefits to families and to help them "navigate the systems" is essential. A significant drop in Wisconsin's Medicaid rolls from 1995 through 1997 underscored the need for more effective outreach. In that context, the Wisconsin Maternal and Child Health Program, in coordination with Medicaid, the State Medical Society, and local public health, carried out a vigorous campaign to promote Medicaid and BadgerCare outreach, with notable results. Outreach initiatives included stationing on-site Medicaid enrollment workers in hospitals and clinics, the development of simple to understand brochures in three languages, training of enrollment workers as well as local health departments and community based organizations, a new hotline for consumers with questions about the enrollment process, and media campaigns in specific geographic areas. In addition, Medicaid allocated a portion of the outreach funds to go to local public health departments to help families in the enrollment process; to improve vaccination coverage, primarily among children under two years of age; and to work with schools to identify uninsured children. These efforts are bearing fruit both for Medicaid and BadgerCare. BadgerCare, which covers uninsured children and their parents with household incomes below 185 per cent of the federal poverty level, enrolled 60,000 people in its first nine months from January through March 2000. The percentage of BadgerCare eligible people who are enrolled is significantly greater than other states' CHIP enrollments at similar program stages. One significant indicator of overall outreach success is that 30 percent of BadgerCare recipients had not previously received other major public assistance programs such as WIC and family planning. The State Medical Society of Wisconsin has performed a central role in Medicaid outreach, from strong policy endorsement to brochure distribution, especially for "working poor" families. Physicians and their office staff are valuable assets in Medicaid outreach and enrollment. 5. Cultural Competence - The United States Surgeon General, Dr. David Satcher, has established a Year 2010 public health objective of 100 % access to health care and zero disparities in health status for all citizens. The attainment of such an ambitious and significant public health objective depends on the capacity of all of our health systems to deliver culturally competent care. Rapid change in the organization and delivery of health care and the increasing diversity of the U. S. population, including that of Wisconsin, heighten the importance of striving to incorporate cultural competence into the provision of health care. MCH practitioners are well poised to play a central leadership role in this effort, and many have already done so. The Five Guiding Principles Organizational Self-Assessment encourages Title V funded organizations to become more aware of their capacity and needs for becoming more culturally competent. A 1998 Work Group convened by the Wisconsin MCH Program came up with a series of recommendations for implementing culturally competent practices. Recommendations addressed the importance of MCH programs to educate themselves on this issue; to advocate within their own organizations for policy changes that place a value on diversity; to become conscious of the dynamics inherent when cultures interact; to develop institutionalized cultural knowledge; and to put into practice adaptations to service delivery that reflect an understanding and honoring of cultural diversity. Finally, the Work Group recommended that programs collaborate with diverse partners to ensure that their communities recognize cultural competence as a high priority and foundation for healthy and safe children and families. The National Center for Cultural Competence at Georgetown University has provided us with valuable assistance as we strive to apply these recommendations to Title V funded programs. Wisconsin uses the 1989 monograph, Toward a Culturally Competent System of Care, for its definition of cultural competence. According to this definition, cultural competence is a set of congruent behaviors, attitudes, and policies that enable a system, organization, or medical practice to work effectively in cross-cultural situations. Culturally sensitive health care involves the individual provider's awareness of and respect for the beliefs of people of various backgrounds. Cultural competence, on the other hand, encompasses such awareness and respect at the institutional or organizational level. The Wisconsin MCH Program operates under the assumption that an honest organizational self-assessment and awareness of the impact of an organization's culture on services to families are central to getting started in the practice of cultural competence. In fact, we affirm the process of self-assessment as key for getting started. We do this because we realize that the path to culturally competent practices follows a long continuum from cultural destructiveness to cultural proficiency, and that agencies are currently at multiple stages in this process. Division of Public Health staff will work with the Title V funded projects, including local health departments to assure that, in their work plans, they set aside resources for culturally competent services and policies with detailed justification for the amount to be spent; demonstrate work done to become more culturally competent; describe how these are put into practice through training, job descriptions, hiring practices, program guidelines, mission statement, staff evaluations, consultants, subcontractors, and modes of communication within the agency and with recipients of services; include people of diverse cultures in all partnerships and collaborations; use evaluation methodologies that draw on input from the diverse cultures in the community and reflect a sensitivity to cultural behaviors, attitudes, and preferences; document written policies and procedures that address communication needs such as easy to understand educational materials (written, oral, and visual) and translators who can communicate at a skill level that is conversational and respectful of the culture; incorporate culture-specific medical practices, spiritual healing, and traditional beliefs; move toward a staffing pattern that reflects the diversity of the community; include questions about cultural competence in the hiring process; and integrate cultural celebrations into day to day operations. The National Center for Cultural Competence has provided Wisconsin with fruitful technical assistance in launching this effort. Summary Since 1993, the Wisconsin MCH Program has rooted many of its efforts in family and community health in the premise that our essential leadership purpose includes but goes beyond the prevention of morbidity and mortality and the reduction of risk. The essence lies in our leadership capacity to foster environments in which children and families can grow and thrive and live compassionate, productive, and dignified lives. Underlying this premise is the hypothesis that how we live together - the quality and meaning and connectedness of our relationships in family and community - has a powerful influence on our health, well being, and safety. Our most fundamental goal driving the way we do business is to facilitate the collaboration, support systems, and strengths to allow for our citizens to grow and live in healthy ways. The underlying assumption is that human beings, at their best, seek positive connections with each other, and that these connections enrich all of our lives. We are excited about a new book that summarizes a great deal of the research that lends support to this hypothesis, thus challenging us to probe more deeply about how we can best apply these ideas to our programs, services, policies, and systems in public health. The book is "Bowling Alone: The Collapse and Revival of American Community" by Robert D. Putnam (New York: Simon & Schuster, 2000). In this groundbreaking book based on vast new data, Putnam shows how we have become increasingly disconnected from family, friends, neighbors, and our democratic structures-- and how we may reconnect. Putnam warns that our stock of social capital - the very fabric of our connections with each other, has plummeted, impoverishing our lives and communities. Putnam draws on evidence including nearly 500,000 interviews over the last quarter century to show that we sign fewer petitions, belong to fewer organizations that meet, know our neighbors less, meet with friends less frequently, and even socialize with our families less often. We're even bowling alone. More Americans are bowling than ever before, but they are not bowling in leagues. Putnam shows how changes in work, family structure, age, suburban life, television, computers, women's roles and other factors have contributed to this decline. Future Search has served us well as a powerful tool for increasing social capital and for putting into practice our hypothesis that how we live together - the quality and meaning and connectedness of our relationships in family and community - has a powerful influence on our health, well being, and safety. |
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