Kimberly D. Williams Master's Thesis

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    No Health Without Mental Health:

    Innovative Solutions to Creating Change in Behavioral Health Care

    A Thesis

    Submitted to the Faculty

    of

    Drexel University

    by

    Kimberly D. Williams

    in partial fulfillment of the

    requirements for the degree

    of

    Master of Public Health

    May 2012

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    Copyright 2012Kimberly D. Williams. All Rights Reserved.

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    iii

    ACKNOWLEDGMENTS

    I would like to thank my advisor, Dennis Gallagher, MA, MPA. Theopportunity for me to participate in this project would not have been possible withouthis recommendation. I am truly indebted and thankful for his generous guidance,motivating questions, thoughtful feedback, and unwavering support to both the overall

    project as well as the completion of this thesis.

    I would like to express my appreciation and thanks to Joe Pyle, MA of theThomas Scattergood Behavioral Health Foundation for spearheading this project andinitiating the collaboration with Drexel University. His commitment to theadvancement of behavioral health care through collaborative and innovative effortshas been truly inspiring.

    Additionally, I would like to thank Jason D. Alexander, MA of Capacity forChange, Larry Geiger of Geiger Design, and John A. Rich, MD, MPH of DrexelUniversity School of Public Health for their invaluable contributions throughout theentire course of this project.

    I would like to extend my gratitude to the preeminent community stakeholderswho generously offered their time to participate in our key informant interviews.Their invaluable feedback regarding the current status behavioral health care elevatedour project as well as my personal knowledge to a level of appreciation and awarenessfor which I am very grateful.

    Special thanks to Arthur C. Evans, Jr., PhD of the Philadelphia Department ofBehavioral Health and Intellectual disAbility Services for his additional support andendorsement of the Scattergood Foundation design challenge.

    Last but certainly not least, I would like to thank Katherine Carroll and AlysonFerguson for graciously allowing me to contribute to their Community-Based MatersProject as a part of my Block VIII Independent Study. Without their steadfastdedication to the project, this opportunity would not have been possible for me. I amsincerely thankful for their support, patience, and insight. I have no doubt that they

    will each make an immeasurable contribution to the field of public health in the yearsto come.

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    TABLE OF CONTENTS

    LIST OF TABLES.......................................................................................................v

    LIST OF FIGURES....................................................................................................vi

    1. INTRODUCTION ...................................................................................................1

    2. BACKGROUND ......................................................................................................4

    2.1 No Health Without Mental Health ....................................................................... 4

    2.2 National and Regional Mental Health Care Policy .............................................. 5

    2.3 National and Regional Mental Health Status.....................................................10

    2.4 Social Innovation for Wicked Problems ............................................................12

    2.5 Design Thinking.................................................................................................13

    2.6 Human-Centered Design ....................................................................................15

    2.6.1 Desirability, Feasibility, Viability ...............................................................15

    2.6.2 Hear, Create, Deliver ...................................................................................17

    2.7 Web 2.0 and Social Media..............................................................................18

    2.8 Philanthropy as a Change Agent ........................................................................19

    2.8.1 Dorothy Rider Pool Health Care Trust ........................................................20

    2.8.2 Advancing Colorados Mental Health Care ................................................ 21

    2.8.3 Philanthropy 2.0 ....................................................................................... 23

    3. THE SCATTERGOOD PROJECT .....................................................................24

    3.1The Scattergood Foundation ..............................................................................24

    3.2The Scattergood Project .....................................................................................26

    3.2.1 Project Development ...................................................................................26

    3.2.2 Website Development .................................................................................28

    3.2.3 IRB Submission........................................................................................... 29

    3.2.4 Interview Recruitment .................................................................................29

    3.2.5 Phase 1: Hear .............................................................................................. 30

    3.2.6 Phase 2: Create ........................................................................................... 31

    3.2.7 Phase 3: Deliver.......................................................................................... 33

    3.2.8 Report Writing............................................................................................. 363.3Future of the Scattergood Project....................................................................... 37

    4. LESSONS LEARNED...........................................................................................38

    4.1Personal Narrative .............................................................................................. 38

    4.2Future Executive MPH Student Opportunities...................................................41

    LIST OF REFERENCES..........................................................................................43

    APPENDIX A: INTERVIEW GUIDE....................................................................50

    APPENDIX B: DESIGN BRIEF DRAFT ..............................................................52

    APPENDIX C: LINKS FOR ADDITIONAL INFORMATION..........................54

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    LIST OF TABLES

    1. Scattergood Project Timeline (2011 2012)........................................................26

    2. Key Informant Interview Themes........................................................................32

    3. Design Challenge Model........................................................................................ 33

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    LIST OF FIGURES

    1. Human-Centered Design: Desirability, Feasibility, Viability...........................16

    2. Human-Centered Design: Hear, Create, Deliver...............................................18

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    1. INTRODUCTION

    As the former U.S. Surgeon General, Dr. David Satcher, aptly declared,

    There is no health without mental health. In addition to calls for the integration of

    mental and physical health systems, the field of public health should improve the

    extent to which mental health factors are incorporated into its objectives and

    strategies.

    Over the past 50 years, there have been numerous legislative advancements to

    improve that quality of and access to health care for undeserved Americans including

    Medicaid, Medicare, and most recently the Patient Protection and Affordable Care

    Act (PPACA) (Barr, 2011). In addition to these measures, specific improvements

    have been implemented to improve behavioral health care including the Mental

    Health Parity Act (MHPA) as well as the expanded Paul Wellstone and Pete

    Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) (Frank &

    Giled, 2006). However, the national prevalence and incidence of mental disorders

    remains disturbingly high at 46.4% and 26.2% respectively (Kessler & Wang, 2008).

    As such, the quality and accessibility of behavioral health care continue to be a

    pressing concern. In addition to financial concerns that reduce access to health

    insurance coverage and health care services, another major barrier is the persistence

    of personal and societal stigma surrounding mental illness (Corrigan, 2004; Corrigan,

    Markowitz, & Watson, 2004).

    The multi-faceted issues that contribute to the barriers and deficiencies in the

    behavioral health care systems may be classified as wicked problems. Rittel and

    Webber (1973) cited that due to their complex nature, wicked problems cannot be

    addressed by utilizing traditional scientific methods. Instead, sources of wicked

    problems could be mitigated by the creation and administration of disruptive social

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    innovations (Brown & Wyatt, 2010; Kolke, 2012). Employing the use of design

    techniques may be an effective way to inspire and generate social innovations. Brown

    (2009) asserted that the application of design thinking methodologies, such as human-

    centered design, may in fact be a systematic and integral way to achieve socially

    innovative solutions.

    As design practice has evolved into the application of design thinking methods

    for social causes and concerns, the world of technology has also progressed. Two

    primary examples include the evolution of the World Wide Web into what has been

    coined Web 2.0 as well as the subsequent creation of social media applications.

    The advent of Web 2.0 and its social media tools have enabled users to capitalize on

    the inherently interactive nature and social networking potential of this technology

    (Treese, 2006). As a result, users provide as much information as they receive and

    thus, have shifted from a passive consumer role to a role of active participation

    (Brown, 2009).

    While the introduction of design thinking and Web 2.0 have made significant

    contributions to society, philanthropic foundations have also served as a unique agent

    of change. Specifically, philanthropies have played an integral part in improving the

    health of the local communities they serve. Examples of two local foundations which

    exemplify innovative ways to improve the health of their communities include the

    Dorothy Rider Pool Health Care Trust and Advancing Colorados Health Care Trust

    (Meehan, Kaufman, Carlin, & Palmer, 2001; TriWest Group, 2011a).

    The era of philanthropy 2.0 is seen as another evolution in the development

    of philanthropic foundation operations. This has been precipitated by their utilization

    of Web 2.0 and social media applications to increase the level of communication

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    between the foundations, their grantees, and other strategic partners (Brest, 2012;

    Morozov, 2009).

    The Thomas Scattergood Behavioral Health Foundation in Philadelphia,

    Pennsylvania is a key example of a foundation that has embraced philanthropy 2.0

    strategies. Its mission is to carry forth the goals of the foundations namesake,

    Thomas Scattergood, into the 21st century and continue to advance the field of

    behavioral health (Thomas Scattergood Behavioral Health Foundation [Scattergood

    Foundation], 2012). In addition, the Scattergood Foundation has taken inspiration

    from design thinking methodologies in order to promote social innovations for

    behavioral health care.

    In anticipation of the 200th anniversary of the affiliated Friends Hospital, the

    Scattergood Foundation set out to retool its website. In doing so, it collaborated with

    the Drexel University School of Public Health, Geiger Design, as well as a public

    interest consulting group, Capacity for Change, to implement this project. The

    primary goal of the project was to utilize design thinking practices and Web 2.0

    applications in order to develop a design challenge for the local community. Steps

    from the human-centered design process were conducted in an effort to achieve this

    goal. The revised website went live on May 6, 2012. However, the implementation

    of the initial Scattergood design challenge was postponed until after additional

    feedback and engagement from website users in the community could be obtained.

    The delayed implementation of the Scattergood design challenge presents an

    ideal opportunity for future Drexel Master of Public Health students to actively

    participate in this project. Ultimately, it is anticipated that the design challenges

    presented on the Scattergood website will foster innovative and sustainable

    advancements for the regional and national arenas of behavioral health.

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    2. BACKGROUND

    2.1 No Health Without Mental Health

    The fields of mental health and public health are not mutually exclusive. The

    World Health Organization (WHO) asserted as such in their Constitution when they

    defined health as a state of complete physical, mental and social well-being and not

    merely the absence of disease or infirmity (1946, p. 1). Just as calls to integrate

    mental and physical health care increase, public health should continue this trend by

    improving the extent in which mental health is incorporated into its policies,

    educational programs, communication strategies, prevention research, surveillance

    practices, and epidemiological reviews (Centers for Disease Control and Prevention

    [CDC], 2011b; WHO, 2002).

    Coinciding with the release of the seminal Surgeon General report on mental

    health (U.S. Department of Health and Human Services [DHHS], 1999), Dr. David

    Satcher echoed the sentiments of the WHO Constitution and declared, there is no

    health without mental health. However, what if we took this one step further and

    concluded that there is nopublic health without mental health? In essence, true

    wellness cannot be achieved without holistically addressing the physical, mental, and

    social factors that play a role in our health and well-being. In doing so, it may be

    possible to expand the framework of public health promotion and prevention

    strategies to better include mental health components in their objectives (CDC, 2011b;

    WHO, 2002). With this in place, we may be one step closer to a truly integrated

    health care system where mental health will be accepted as an undeniable and

    invaluable factor in health and wellness.

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    2.2 National and Regional Mental Health Care Policy

    In an effort to offset the rising burden of costs as well as improve the quality

    of and access to services, several reforms to our health care system have been

    implemented during the past 50 years. As a result, our mental health care policies

    have undergone some critical revisions, which have led to dramatic improvements in

    the accessibility and quality of mental health care as well as how society addresses

    and views mental illness. Unfortunately, issues with cost, access to care, system

    fragmentation, and stigma remain a real concern (Giled & Frank, 2009; Frank &

    Giled, 2006; Frank & Giled, 2007).

    In 1965, Medicare and Medicaid were enacted by Congress as amendments to

    the existing Social Security Act and thus, referred to as Title XVIII and XIX

    respectively. The passage of both federal programs marked one of the most

    significant chapters in our countrys history by increasing access to health care for

    millions of Americans. In addition, both reform measures would contribute to

    changing the landscape in which health care services are evaluated and administered

    (Barr, 2011).

    Medicare provides health insurance coverage primarily for individuals who

    are eligible for Social Security benefits and 65 years of age or older. However, it was

    revised a few years later to also include two additional categories of individuals under

    this age limit: those deemed permanently disabled and those in end-stage renal

    disease or what is referred to as kidney failure (Barr, 2011).

    Medicaid currently provides coverage for specified groups of low-income

    individuals and their families or disabled individuals who meet the mandated

    qualifications. Unlike Medicare, which is universally available for all elderly

    individuals, Medicaid was not initially intended to provide coverage for all people

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    who fall below the federal poverty line (FPL) and was only made available to certain

    subgroups that met the eligibility requirements (Barr, 2011). Another notable

    difference between the two programs is that Medicaid is managed by the state and

    local governments with a percentage of program costs being funded by federal

    reimbursements, whereas the federal government solely administers Medicare (Barr,

    2011).

    While Medicaid was not specifically created to increase coverage for

    individuals with mental health concerns, it did considerably reduce the states cost of

    mental health care. As a result, the number of individuals with diagnosable mental

    disorders who received coverage through Medicaid dramatically increased over the

    years (Frank & Giled, 2006; Henry J. Kaiser Family Foundation [KFF], 2011). As of

    2011, approximately 24% of adult Americans enrolled in Medicaid reportedly had a

    diagnosable mental disorder (Garfield, Zuvekas, Lave, & Donohue, 2011).

    One of the mandates included in the initial implementation of Medicaid was

    that services at state and county mental health hospitals or private psychiatric facilities

    would not be covered. This was known as the Institution of Mental Disease (IMD)

    exclusion. The IMD exclusion was included to prevent state costs from shifting to the

    federal budget. Another goal was to encourage state health systems to transition from

    primarily long-term, in-patient mental health care to programs that focused on

    community-based treatments (Frank & Giled, 2006; KFF, 2011). It is now clear that

    the Medicaid IMD exclusion only partially succeeded in this effort. Indeed, Medicaid

    is considered to have played a significant role in the deinstitutionalization of mental

    health services by the dramatic decrease of patients at state and county mental

    hospitals. After a peak of over 550,000 in-patient residents in 1955, there was a

    steady decrease of 1.5% per year during the next ten years. Starting in 1965, the rate

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    jumped to a patient decrease of 8% per year. This was especially evident in the rapid

    reduction of elderly in-patients from these facilities, which totaled about 70.6%

    between 1955 and 1973 (Frank & Giled, 2006). However, many patients were in fact

    only transferred to other types of in-patient care, specifically psychiatric wards in

    general hospitals and nursing homes. In particular, there was a 74% increase of

    elderly patient residents in nursing homes between 1960 and 1970 (Frank & Giled,

    2006).

    Despite some improvements, the marginalization of behavioral health care

    continued and the fragmentation between behavioral and physical health care was

    only perpetuated by these new legislations (Frank & Giled, 2006). In fact behavioral

    health services were literally carved out of the general health system and thus

    managed under a separate funding structure (Frank & Giled, 2006; Zuvekas, 2005).

    A prime example of the fragmentation of mental health care can be seen in

    Pennsylvanias public welfare system. Under the states Department of Public

    Welfare (DPW), the HealthChoices program consists of two divisions that administer

    managed care programs for residents who receive medical assistance (DPW, 2010a).

    The Office of Mental Health and Substance Abuse Services (OMHSAS) division runs

    the behavioral health managed care organizations (DPW, 2012). The Office of

    Medical Assistance Programs (OMAP) runs the physical health managed care

    organizations and administers the Medicaid program for the state (DPW, 2010b). As

    such, state residents in need of medical assistance are forced to navigate between two

    complex health systems in order to receive comprehensive care for behavioral and

    physical conditions.

    While many new Americans obtained health care coverage through the

    creation of Medicaid and Medicare, the costs for health care rapidly increased since

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    their inception (Barr, 2011). One response to these rising costs was the increased

    utilization of managed health maintenance organizations (HMOs) and managed

    behavioral health care organizations (MBHOs) during the 1980s and 1990s (Barr,

    2011; KFF, 2011). However, the increase usage of managed care organizations

    contributed to furthering the marginalization and fragmentation of behavioral health

    care services from the rest of the health care system (Brousseau, Langill, & Pechure,

    2003; KFF, 2011; Zuvekas, 2005).

    In response to these issues, the Mental Health Parity Act (MHPA) was enacted

    in 1996. The MHPA set a historic precedent by mandating that insurance carriers

    provide mental health care benefits and limits that are equal to medical and surgical

    health care benefits and limits (KFF, 2011; Smaldone & Cullen-Drill, 2010). In 2008,

    the benefits provided by the MHPA were further increased with the Paul Wellstone

    and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). The

    parity requirements under the MHPAEA were expanded to include substance use

    disorders as a mental health condition and eliminated arbitrary limits on the frequency

    of outpatient treatment services or inpatient days of coverage (Smaldone & Cullen-

    Drill, 2010). The additional mandates in the 2008 MHPAEA went into effect on

    January 1, 2010 (Smaldone & Cullen-Drill, 2010).

    That same year would mark a historic evolution for general as well as

    behavioral health care with the passage of the Patient Protection and Affordable Care

    Act (PPACA), which was signed into law on March 23, 2010 (Garfield, Lave, &

    Donohue, 2010). While the MHPAEA sought to equalize the mental and physical

    health care coverage, the PPACA attempted to take health care to the next level by

    increasing accessibility, improving quality, as well as integrating mental and physical

    health services (Barry & Huskamp, 2011; Garfield et al., 2010). The principle behind

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    the PPACA was that all Americans should be provided access to affordable health

    care insurance in order to have access adequate health care services and thus, improve

    to overall health status of the nation (Barry & Huskamp, 2011; Garfield et al., 2010).

    Of the 59 million people currently enrolled in Medicaid, approximately only

    5% are eligible directly due to a mental disorder. The majority of people currently

    qualify for Medicaid based on their family or low-income status (KFF, 2011). As a

    direct result of the PPACA, approximately 2 million additional Americans who meet

    the criteria for a mental disorder will be eligible for Medicaid after the full PPACA

    provisions are enforced by 2014 (KFF, 2011). This increased rate of coverage will

    primarily be possible due to updated eligibility requirements (Garfield et al., 2011).

    Specifically, Medicaid will be expanded to include all persons with household

    incomes up to 133% of the FPL (Barr, 2011; KFF, 2011). In addition, persons with

    household incomes up to 400% of the FPL will be eligible for subsidies to supplement

    the purchase of health care coverage through health insurance exchanges (Barr, 2011;

    KFF, 2011).

    Another crucial and historic component of the PPACA for the mental health

    community is the inclusion of behavioral health care services as an essential health

    benefit (Garfield et al., 2010). This will prohibit affected health insurance plans from

    excluding individuals with pre-existing behavioral health conditions. As a result,

    many more individuals with diagnosed mental illnesses or substance use disorders

    who were previously unable to obtain private insurance or Medicaid benefits, will

    now be eligible for some form of health insurance that will cover their physical and

    behavioral health care needs (Garfield et al., 2010). It is expected that approximately

    3.7 million Americans with mental disorders will be able to obtain some form of

    health care coverage by 2019 (Garfield et al., 2011; KFF, 2011). The PPACA has the

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    potential to reshape the way behavioral health services are delivered in this country

    and could measurably reduce the system fragmentation between behavioral and

    physical health care (Barry & Huskamp, 2011; Garfield et al., 2011).

    As of May 2012, the U.S. Supreme Court was currently debating the

    constitutionality of the PPACA. It remains to be seen whether the court will uphold

    the full PPACA, only certain provisions such as the individual mandate to purchase

    health insurance, or strike down the Act in its entirety (New York Times, 2012).

    Regardless of future outcomes, it is clear that more policy and system changes are

    needed to ensure that Americans receive truly adequate behavioral health care

    treatment and services. In addition, more needs to be done to change societys

    outlook on mental illness as well as the importance of overall mental wellness.

    2.3 National and Regional Mental Health Status

    Kessler and Wang (2008) confirmed that the national prevalence of mental

    disorders remains exceedingly prohibitive. In their epidemiological review of mental

    disorders as categorized in theDiagnostic and Statistical Manual of Mental

    Disorders 4th Edition (DSM-IV) they reported that approximately half (46.4%) of

    the U.S. population would meet the diagnosable criteria for one or more disorder

    during their lifetime. In addition, more than a quarter (26.2%) of the U.S. population

    would meet the criteria for such a disorder during any given 12-month period (Kessler

    & Wang, 2008). The state of Pennsylvania was slightly below this national average

    with approximately 17.74% of adults over the age of 18 meeting the criteria for a

    diagnosable mental illness between 2008 and 2009 (Substance Abuse and Mental

    Health Services Administration [SAMHSA], 2011). However, 26.24% of young

    adults between the ages of 18 and 25 did meet the criteria for a diagnosable mental

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    illness, which is an alarming rate for this age category and more in line with national

    prevalence rates of adults (SAMHSA, 2011).

    The percentage of individuals who exhibit co-occurring mental health

    disorders as well as comorbid physical health conditions has been identified as

    another public health concern. Kessler and Wang (2008) cited that well over a quarter

    (27.7%) of Americans will experience two or more mental disorders during their

    lifetime and that approximately 17% are at risk for experiencing three or more mental

    disorders. In addition, several studies have confirmed that adults with mental

    disorders are more likely to be afflicted with comorbid physical health conditions

    such as high blood pressure, heart disease, stroke, diabetes, and asthma (Chapman,

    Perry, & Strine, 2005; Goodell, Druss, & Walker, 2011; Institute of Medicine, 2006;

    Parks, Svendsen, Singer, & Foti, 2006; SAMHSA, 2012a).

    Adult Americans with mental disorders are also more likely to utilize

    emergency department (ER) services (38.8%) or be hospitalized (15.1.%) than those

    who do not have a diagnosed mental disorder (27.1% and 10.1% respectively)

    (SAMHSA, 2012a). The origin of such differences between the health status of

    individuals with and without mental disorders has yet to be empirically identified.

    However, it is clear that individuals with mental disorders disproportionately suffer

    from chronic health conditions and thus demonstrate a greater need for physical health

    care treatment in addition to mental health services (SAMHSA, 2012a; Goodell et al.,

    2011).

    Despite the known prevalence of mental health disorders as well as their

    association with an increased risk of comorbid physical health conditions, many

    individuals fail to seek out treatment for behavioral health related concerns nor follow

    through with recommended services (Corrigan, 2004; Corrigan et al., 2004; KFF,

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    2011). In fact, as many as 60% of adults with a diagnosable mental disorder were

    reported to not have received necessary mental health care services (KFF, 2011). One

    confirmed reason is due to the continuing high rates of individuals who do not have

    health insurance coverage and could not afford the cost of such services (Garfield et

    al., 2011; KFF, 2011, SAMHSA, 2012b). In 2010, about 43.7% of adults reported

    that the primary reason they did not receive necessary mental health services was

    directly due to issues with the cost of such care (SAMHSA, 2012b). In addition to the

    known financial barriers to care, many individuals do not obtain necessary behavioral

    health treatment due the social stigma associated with mental illness (Corrigan, 2004;

    Corrigan et al., 2004).

    2.4 Social Innovation for Wicked Problems

    Rittel and Webber (1973) identified wicked problems as issues that plague

    our society and, due to the complex social systems in which they are entrenched,

    cannot be tackled with traditional scientific applications. Instead, the exploration and

    creation of disruptive innovations have been identified as a possible means to mitigate

    the factors that contribute to the wicked problems of our society (Brown & Wyatt,

    2010; Kolke, 2012). Thus a movement has been initiated to develop social

    innovations through alternative means in order to effectively address such wicked

    problems (Brown & Wyatt, 2010; Phills, Jr., Deiglmeier, & Miller, 2008). In

    response to this movement, the utilization of modified design techniques have been

    touted as an effective way to produce potentially innovative solutions (Brown &

    Wyatt, 2010; Kolke, 2012).

    In order to reduce the many barriers to care and improve the quality of

    behavioral health services, disruptive social innovations may be the best solution to

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    their wicked problems. The application of design thinking practices, including

    human-centered design, may thus be an opportune way to foster socially innovative

    thinking and create tangible solutions to some of the critical systemic and cultural

    behavioral health concerns that affect our society.

    2.5 Design Thinking

    In his book, Change By Design, Tim Brown asserted that design thinking is

    a systematic and integral approach for achieving innovated solutions (2009). Some

    identified best practices for the design thinking process include the use of dedicated

    spaces, finite or well-defined timeframes, and multi-disciplinary teams (IDEO, 2009).

    In addition, Brown asserted that the design process includes three fundamental levels

    or spaces of thinking when trying to develop an innovative solution: inspiration,

    ideation, and implementation (Brown, 2009; Brown & Wyatt, 2010). These spaces of

    thoughts are not classified as distinct steps in a process because design thinking is

    iterative (Brown, 2009; Liedtka & Ogilvie, 2011). In fact, such levels of thinking are

    not necessarily completed sequentially and may be repeated throughout the process of

    developing a product or solution (Brown, 2009; Brown & Wyatt, 2010; Liedtka &

    Ogilvie, 2011).

    The initial level ofinspiration may involve creating a brief, which documents

    the facts and background concerning the issue at hand and defines the problem. It

    also includes the process of exploring the issues, needs and barriers of the target

    population affected by the problem. This can best be achieved by immersing oneself

    into the daily lives and routines of individuals and observing them in natural

    environment (Brown & Wyatt, 2010).

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    The second concept, ideation, involves analyzing and synthesizing the

    information that was collected in order to eventually formulate potential solutions.

    Ideation largely involves active divergent thinking in which many thoughts and ideas

    are generated in order to facilitate the creation of potential options or solutions.

    Ideally, this involves brainstorming sessions with multi-disciplinary teams that

    provide varied backgrounds and alternative perspectives, which advance the divergent

    thinking process (Brown, 2009; Brown & Wyatt, 2010). In addition, design

    challenges have also proven to further develop divergent thinking by successfully

    fostering multiple ideas and potential solutions for the problem in question. The

    design challenge process is initiated when a challenge question is posted in some

    central location for individuals or teams to review, offer comments, and design

    potential solutions (Brown & Wyatt, 2010). Aside from generating multiple thoughts

    and idea, participating can elevate people from a passive position to an active one

    where they are engaged and committed to the issue as well as its eventual solution

    (Brown, 2009). During the ideation process, the team will eventually transition from

    a level of divergent thinking to a level of convergent thinking where the abstract

    information collected is focused down into a few concrete ideas and solutions

    (Brown, 2009; Brown & Wyatt, 2010).

    Finally, implementation is self-explanatory to the extent that it involves setting

    up a plan for implementation to final solution. This also may involve the creation of a

    communication strategy and prototypes to ensure that the solution is effectively and

    efficiently implemented (Brown, 2009; Brown & Wyatt, 2010).

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    2.6 Human-Centered Design

    One of the core principles in design thinking is to maintain processes and

    goals that are fundamentally human-centered(Brown, 2009; Brown & Wyatt, 2010).

    As a result, the human-centered design methodology was created in an effort to

    systematically incorporate the needs of the people for whom the design product is

    intended. Originally created to enable for-profit corporations a way to design

    products and create innovative solutions or concepts for their businesses, the tools in

    human-centered design have been discovered to be an innovative way to create

    solutions and promote change for social causes and community related concerns

    (Brown, 2009; Brown & Wyatt, 2010).

    By its very name, a human-centered process or project begins with the people

    it is tasked with supporting through its innovations. Constantly keeping the

    framework focused on the human component of the project and involving the

    consumers throughout the design process ensures that the final product is truly

    desirable, feasible, viable, and ultimately sustainable (Brown, 2009; Brown & Wyatt,

    2010).

    2.6.1. Desirability, Feasibility, Viability

    The human-centered design process begins with three lenses by which the

    team views and evaluates the problem at hand: Desirability, Feasibility, and Viability

    (see Figure 1) (Brown, 2009; IDEO, 2009). The first lens,Desirability, is the basis of

    all human-centered thinking and processes. The consideration of what the target

    population desires and not what the evaluator believes that they need is the framework

    from which future solutions or concepts are derived (Brown, 2009; IDEO, 2009). The

    second lens,Feasibility, reminds the team to ensure that all solutions are anchored in

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    proposals that are considered organizationally and technically feasible (Brown, 2009;

    IDEO, 2009). Finally, even the most organizationally and technically feasible

    solution cannot be sustainably implemented without being financially viable.

    Therefore, the third lens ofViability maintains that the solutions achieved retain a

    realistic and practical approach in their implementation (Brown, 2009; IDEO, 2009).

    If the final solutions created from a human-centered design process encompass all

    three of these lenses in their product or concept then it increases the likelihood that

    they will be successfully implemented and received by the community for which they

    were conceived (Brown, 2009).

    Figure 1. Human-Centered Design Lenses: Desirability, Feasibility, Viability.Adapted fromHuman-Centered Design Toolkit, 2ndEditionby IDEO, 2009, p. 6.

    Copyright 2012 by IDEO.

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    2.6.2. Hear, Create, Deliver

    The actual steps of a human-centered design process are implemented by

    utilizing techniques and specific activities in three distinct phases: Hear, Create, and

    Deliver (see Figure 2) (IDEO, 2009). These phases mirror the concepts of inspiration,

    ideation, and implementation that Brown asserted are instrumental in the design

    thinking process (Brown, 2009; Brown & Wyatt, 2010). TheHearphase begins with

    compiling concrete information and facts about the problem at hand as well as the

    people affected by this problem. This information is obtained by conducting field

    research where people are observed in their environment and encouraged to provide

    stories about their daily lives and routines (IDEO, 2009). During the Create phase,

    the concrete information collected is analyzed and expanded into abstract themes or

    concepts. These multiple ideas are then synthesized into opportunities or options and

    eventually into concrete solutions for the problem (IDEO, 2009). TheDeliverphase

    prepares for the release of the agreed upon solution. This may involve the

    development of prototypes or models to serve as a guide for the solution concept. In

    addition, an implementation plan is created and eventually initiated in order to

    effectively release the final solution into the community (IDEO, 2009).

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    Figure 2. Human-Centered Design Phases: Hear, Create, Deliver. Adapted from

    Human-Centered Design Toolkit, 2nd

    Edition by IDEO, 2009, p. 7. Copyright 2012by IDEO.

    2.7 Web 2.0 and Social Media

    Technology is a continuously evolving factor within the development of our

    society. The evolution of the World Wide Web into what has been coined Web 2.0

    is yet another milestone in that development. During the past two decades, the way in

    which we utilize the Web to access and disseminate information has shifted from a

    unilateral experience to a multilateral phenomenon. Two hallmarks of Web 2.0 are its

    interactive nature and social networking capabilities (Treese, 2006).

    Prime examples of both these functions are encapsulated in current social

    media tools such as Facebook, Twitter, and YouTube (CDC, 2011a). Kaplan and

    Haenlein (2010) defined social media as a group of Internet-based applications that

    build on the ideological and technological foundations of Web 2.0, and that allow the

    creation and exchange of User Generated Content (p. 61). In other words, social

    media technologies allow for users to interact and actively participate in the content

    they are accessing rather than simply passively consuming information. As asserted

    by Brown (2009), Web 2.0 users have shifted from a consumer role to a participatory

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    role with the assistance of social media applications. As a result, Web 2.0

    applications are particularly well suited to serve as a forum for the human-centered

    design process where the users input is a fundamental part of its method.

    2.8 Philanthropy as a Change Agent

    Philanthropic foundations are in an ideal positionto promote change and

    foster innovation in our society. Furthermore, local philanthropies have the ability to

    produce a great deal of change within the communities they serve. Meehan,

    Kaufmann, Carlin, & Palmer (2001) identified some of the most distinct advantages

    local philanthropies have when attempting to produce change. First, they noted that a

    well-designed philanthropic agenda could have a strong influence on the local

    communities served. Second, they have the ability to maintain a neutral and honest

    mediating position between the design and implementation of change into a

    community. Third, as a private foundation, they do not have the same level of

    political considerations as elected officials or departments. As a result, they may be

    in a position to fund or even implement more innovative and groundbreaking

    solutions. Fourth, philanthropies have the ability to dispense smaller amounts of

    funds in a more strategic and targeted fashion than larger government organizations

    and thus, are able to respond to a need more effectively and efficiently. Fifth, they

    can uphold a reputation of reliability and integrity by championing causes that may

    have been previously discarded for financial or political reasons. Lastly, through

    effective fundraising efforts, philanthropies can maintain a greater level of financial

    resources than other types of organizations in order to create an improved and

    sustainable system of care (Meehan et al., 2001).

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    With health related issues being one of the foremost concerns addressed today,

    philanthropies have played a crucial role in advancing health care systems as well as

    the well-being of underserved populations (Grantmakers In Health [GIH], 2005, 2010,

    2012). One of the most underserved populations includes individuals dealing with

    behavioral health concerns. Philanthropies are particularly suited to navigate a

    complex behavioral health care system and improve some of its deficiencies and

    difficulties in order to increase its quality and access to care (Brousseau, Langill, &

    Pechura, 2003; LeRoy, Heldring, & Desjardins, 2006; Meehan et al., 2001).

    2.8.1 Dorothy Rider Pool Health Care Trust

    A prime example of such a foundation is the Dorothy Rider Pool Health Care

    Trust (Pool Trust) located in Allentown, Pennsylvania. The Pool Trust was created in

    1975 with a mission to ensure quality health care for local residents and provide

    funding assets to Lehigh Valley Hospital that serves the region (Dorothy Rider Pool

    Health Care Trust, n.d.; Meehan et al., 2001). In an effort to combat the increasing

    challenges of the areas psychiatric system, the Pool Trust attempted to reduce the

    number of patients who sought out psychiatric services through local emergency

    departments and redirect their treatment to community-based care. A second goal

    was to implement a sustainable system that ensured the long-term support of these

    patients as well as their ability to thrive as functional members of the community

    (Meehan et al., 2001).

    Several notable achievements have been documented despite the fact that a

    formal evaluation of this initiative has not been conducted. First, over $5.2 million of

    funds were provided by the Pennsylvania Department of Public Welfare (DPW) to

    support the expansion of community-based behavioral health services. Thus, the

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    amount of community services increased for patients classified at a high risk for in-

    patient care (Meehan et al., 2001). In addition, the utilization of services at Allentown

    State Hospital (ASH), which is a long-term and in-patient psychiatric facility, were

    reduced. This was demonstrated by the fact that more than 100 patients at ASH were

    discharged and successfully integrated into the community. Additional services for

    psychiatric crises and alternatives to in-patient hospitalization were also implemented

    as a result of this program (Meehan et al., 2001). In order to independently gauge the

    communitys response to the program initiatives, local mental health consumers and

    their families created a Customer Satisfaction Team. They monitored the services

    provided and evaluated the systems efforts through the use of surveys, which have

    demonstrated positive results and sustained customer approval (Meehan et al., 2001).

    2.8.2 Advancing Colorados Mental Health Care

    Local philanthropies can also collaborate among each other in order to foster

    change in a community. In 2002, eight local foundations collaborated to assess the

    status of mental health care in the state of Colorado. These foundations included:

    Caring for Colorado Foundation, The Colorado Trust, Daniels Fund, The Denver

    Foundation, First Data Western Union Foundation, HealthONE Alliance, Rose

    Community Foundation, and Rose Womens Organization. They commissioned a

    private consulting group, TriWest Group and Heartland Network for Social Research

    (TriWest Group), to complete an evaluation of the private and public mental health

    systems in Colorado. The result of this assessment was released in the 2003 report,

    The Status of Mental Health Care in Colorado (TriWest Group, 2003). This

    evaluation revealed the extreme fragmentation of mental health services and how this

    inhibited access to care for the states residents. Specifically, they noted that one in

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    five residents are in need of mental health care, but only approximately a third of

    these individuals receive treatment. In addition, they identified that children and

    adolescents contribute to more than a third of the states severe mental health needs,

    but only comprise a quarter of the overall states population. Only half of children

    from households that were classified as low-income received necessary mental health

    care in 2000 (TriWest Group, 2003).

    In response to the alarming findings in this report, Advancing Colorados

    Mental Health Care (ACMHC) was created through the joint funds of the Caring for

    Colorado Foundation, the Colorado Trust, the Denver Foundation, and the Colorado

    Health Foundation (previously known as the Health ONE Alliance). Together they

    committed $4.25 million for a five-year project between 2005 and 2010 to improve

    Colorados mental health care system by increasing the integration and coordination

    of its services (TriWest Group, 2011a). The ACMHC project funded six grantees for

    three integration-related project goals. The first funded two grantees for projects to

    integrate mental health and substance use disorder services. The second funded two

    grantees for projects to integrate mental health and primary health care services. The

    third funded two grantees for projects to integrate mental health services with school

    settings (TriWest Group, 2011a).

    In 2011, an updated report The Status of Behavioral Health Care in

    Colorado was released that reviewed the successes of the ACMHC project as well

    as what needs remained a concern for the state (TriWest Group, 2011b). This report

    demonstrated the number of mental health and substance use disorder practitioners

    increased from 10,564 in 2003 to 14,217 in 2011. However, a high need remained for

    specialists who are able to treat complex behavioral health issues and practitioners for

    services in rural and frontier areas of the state (TriWest Group, 2011b). Spending on

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    public mental health care across the state did increase between 2002 and 2009, with a

    per capita increase from $62 to $84 (TriWest Group, 2011b). In addition, several

    efforts have been made to reduce system fragmentation in the states mental health

    care system. For example, oversight of the mental health and substance use disorder

    care systems are now both managed by their Division of Behavioral Health.

    Increased availability of medical home services for children and adolescents was also

    reported (TriWest Group, 2011b).

    2.8.3 Philanthropy 2.0

    In the pursuit to find new ways to raise funds and create change for their

    prioritized causes, philanthropies have begun to utilize Web 2.0 and social media in

    their operational and communication strategies (Brest, 2012). The utilization of such

    innovations has ushered in the advent of philanthropy 2.0 where the lines of

    communication between the foundations, their grantees, and other partners are closer

    than ever (Brest, 2012; Morozov, 2009).

    Another transformation in the field of philanthropy was the increased usage of

    design thinking methods, which were initially developed within the for-profit

    industry. Prior to its incorporation by philanthropic foundations, many non-profit

    organizations began to adopt the for-profit design thinking approaches in order to

    create change and foster socially innovative ideas. This resulted in the differences

    between non-profit and for-profit organizations becoming blurred and less distinct. In

    fact, the increased demand for and creation of social innovations has helped to bridge

    the gap between non-profit and for-profit organizations (Phills, Jr. et al., 2008). Many

    philanthropic foundations have now begun to take inspiration from for-profit and non-

    profit organizations by incorporating design thinking techniques into their initiatives

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    as well. Being that the organizational goals of philanthropies are already focused on

    advancing social causes and thus human-centered, the application of design thinking

    strategies is a natural progression for their operational strategies.

    A current example of the recent changes to philanthropic strategies can be

    found in the Thomas Scattergood Behavioral Health Foundation of Philadelphia,

    Pennsylvania. With the assistance of Web 2.0 technology and design thinking

    methods, it continues to promote the creation of socially innovative solutions in order

    to address behavioral health issues and concerns of the region.

    3. THE SCATTERGOOD PROJECT

    3.1 The Scattergood Foundation

    The roots of the Thomas Scattergood Behavioral Health Foundation can be

    traced back to 1811 when Thomas Scattergood, a Quaker minister moved by his

    personal and missionary experiences with mental illness, proposed creating an asylum

    for individuals deprived of the use of their reason at the Philadelphia Yearly

    Meeting (Roby, 2011). In the following year, several Quaker community members

    including Thomas Scattergood gathered in Philadelphia, Pennsylvania and established

    the Friends Asylum for Persons Deprived of the Use of Their Reason (Roby, 2011).

    This asylum would later be founded as Friends Hospital in 1813 and was the first

    private psychiatric hospital in the United States (Scattergood Foundation, 2012).

    Unfortunately, Thomas Scattergood died the following year of Typhus fever.

    However, his son, Joseph Scattergood, was given the opportunity to continue his

    fathers cause and was appointed one of the first managers of Friends Hospital. In

    memory of the man who pioneered the American mission to improve the treatment

    and quality of life for individuals suffering from mental illness, the main building and

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    heart of the Friends Hospital campus was named after Thomas Scattergood (Roby,

    2011; Scattergood Foundation, 2012).

    The Thomas Scattergood Behavioral Health Foundation is a philanthropic

    organization that was established in 2005 as result of a joint venture between Friends

    Hospital and Horizon Health Systems (Scattergood Foundation, 2012). The mission

    of the Scattergood Foundation is to continue the advancement and awareness of

    behavioral health issues that Thomas Scattergood had advocated almost two centuries

    before. With its headquarters located on the Friends Hospital campus, the

    Scattergood Foundation has strived to carry forth the mission of Thomas Scattergood

    into the twenty-first century by fostering a dialogue and increasing learning

    opportunities in the behavioral health field and promoting innovative leadership and

    community collaborations through philanthropic and grant-making opportunities

    (Scattergood Foundation, 2012).

    Since its creation, the Scattergood Foundation has made several contributions

    to the advancement of behavioral health in the Southeastern Pennsylvania community.

    One example of its efforts included providing a grant to help found the Scattergood

    Program for the Applied Ethics of Behavioral Health at the University of

    Pennsylvania. Founded in June 2007, the Scattergood Ethics program is dedicated to

    the promotion, evaluation, and training of the clinical issues and strategies

    surrounding behavioral health care ethics (Scattergood Foundation, 2012). In

    addition, the Scattergood Foundation helped to advance the field of the mental health

    journalism by establishing a position at Philadelphias public broadcasting station,

    WHYY, with the objective of reporting on behavioral health current events and issues

    (Scattergood Foundation, 2012).

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    3.2 The Scattergood Project

    In anticipation of the 200th anniversary of Friends Hospital, the Scattergood

    Foundation set out to redesign its website and incorporate some interactive Web 2.0

    elements, including a design challenge initiative. By revitalizing the website design,

    the Scattergood Foundation sought to advance the level of community dialogue

    around current behavioral health issues in the region and foster innovative ways to

    address such concerns. Over the course of the past nine months, the following

    activities were conducted in an effort to meet this goal (see Table 1).

    Table 1. Scattergood Project Timeline (2011 2012)

    Project Activity Sep Oct Nov Dec Jan Feb Mar Apr May

    Project Development X X

    Website Development X X X X X X X X X

    IRB Submission/Approval X X* X

    Interview Recruitment X X

    Phase 1: Hear X X X* X*

    Phase 2: Create X* X* X*

    Phase 3: Deliver X* X*

    Report Writing X X X* X* X* X* X*

    Note. * Executive MPH student activity/participation

    3.2.1 Project Development

    The inception of the Scattergood Project began when the president of the

    Scattergood Foundation, Joseph Pyle, MA, approached faculty at the Drexel

    University School of Public Health, Department of Health Management and Policy

    Dennis Gallagher, MA, MPA and John A. Rich, MD, MPH and requested Drexel to

    collaborate with the Scattergood Foundation on an initiative to retool the Scattergood

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    website. In addition, Jason Alexander, MA, of the public interest consulting firm,

    Capacity for Change, was brought on as a design thinking advisor for the project and

    Larry Geiger of Geiger Designs was enlisted as the projects graphic designer to build

    the new website.

    A final component of the project team included the recruitment of Drexel

    students in the Masters of Public Health (MPH) program. Initially, two full-time

    students, Katherine Carroll and Alyson Ferguson, were recruited to participate in this

    initiative for their Community-Based Masters Project (CBMP), Fostering Social

    Innovation Through the Use of Web 2.0. At a later point during the development of

    the project, I joined the team to collaborate with the full-time students for the

    completion of my Executive MPH Block VIII Independent Study. Throughout

    September and October 2011, the full-time MPH students initially conceptualized the

    project goals. As presented in a project proposal submitted to the Drexel University

    IRB, these goals were identified as:

    Identify and prioritize system and policy gaps in the behavioral healthsystem in Southeastern Pennsylvania using the human-centered design

    process. Evaluate the process of using human-centered design and Web 2.0 in

    respect to creating behavioral health content for public use on theinternet.

    Create a question(s) to post on the Scattergood website for thebehavioral health community to discuss and potentially create asolution using the human-centered design thinking process.

    The students were tasked with collecting the necessary information and ultimately

    creating a design challenge question for the revised Scattergood Foundation website.

    The inspiration that would serve as the framework for the design challenge question

    was obtained by utilizing elements of the human-centered design methodology in

    order to identify some of pressing barriers, issues, and concerns within the behavioral

    health community. The purpose of the design challenge was based on the dual goals

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    of encouraging an open dialogue among community members and ultimately fostering

    innovative solutions to the proposed behavioral health challenge.

    It was noted that, as in any design project, the formulation of the goals and

    objectives are the result of an iterative process, and subject to revision if necessary.

    For example, it was initially expected that this design challenge question would be

    posted in tandem with the release of the new website. As discussed during the

    Deliver phase of this project, it would later be determined that the design challenge

    release would be postponed until after the website went live.

    3.2.2 Website Development

    Starting in September 2011, Larry Geiger of Geiger Design began working on

    the graphic design development of the new website and continued this process in

    tandem with the rest of the projects development. It was determined that the website

    would be divided into four main quadrants or portals entitled: The Foundation,

    Community Impact, Innovation Awards, and Design Thinking. TheFoundation

    quadrant will provide background and contact information for the Scattergood

    Foundation. The Community Impactquadrant will describe the impact grantmaking

    opportunities can have on communities, provide a database of current grants awarded

    by the Scattergood Foundation, as well as the criteria and guidelines for new grant

    applications. Each year, the Scattergood Foundation presents an award for an

    innovative behavioral health solution, policy or project. TheInnovation Award

    quadrant will provide a background about the annual Scattergood Innovation Award,

    a database of past winners and nominees, as well as the eligibility and judging criteria

    for future contestants. TheDesign Thinkingquadrant will provide some basic

    information about design thinking in general and provide an example of a design

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    thinking application. This quadrant will also host the Design Challenge, where a

    behavioral health challenge question will be posed. Community members will be

    encouraged to participate and engage in this challenge issue as well as create and

    implement an innovative solution.

    3.2.3 IRB Submission

    To prepare the Institutional Review Board (IRB) application, the team

    established the project mission, goals, methods, and overall timeline. In addition,

    appropriate research level training compliance was confirmed for all applications

    listed on the IRB submission by obtaining the following Collaborative Institutional

    Training Initiative (CITI) program certificates: Human Subjects Research and Health

    Information Privacy Security. Once completed, an application for human subjects

    research was submitted October 2011 to the Drexel University College of Medicine,

    Office of Regulatory Research Compliance. By November 2011, the project was

    approved and deemed to be exempt from IRB review since the source of the research

    data would be obtained from interviews with behavioral and public health

    professionals. A secondary factor in this decision was based on the fact that the

    research data would not include the collection of identifying medical data nor direct

    interactions with behavioral health patients.

    3.2.4 Interview Recruitment

    Once IRB approval was received, the project was presented to several key

    stakeholders in the community in order to recruit them for key informant interviews.

    Access to many of the prospective stakeholders was facilitated by referrals from the

    project committee members at the Scattergood Foundation as well as Drexel

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    University School of Public Health faculty. During November and December 2011,

    the Drexel full-time MPH students coordinated the interview recruitment process by

    contacting these referrals, introducing a brief synopsis of the project, and setting up

    times to complete the interviews.

    3.2.5 Phase 1: Hear

    TheHearphase consisted of a literature review and the completion of the key

    informant interviews. A review of the literature was conducted in order to further our

    academic knowledge base of the current behavioral health topics being explored.

    This took place for the full-time students during the summer of 2011 and throughout

    the spring of 2012 for myself.

    The key informant interviews began once IRB approval was received in

    November 2011. The interviews were conducted in order to collect qualitative data

    from key stakeholders regarding behavioral health issues, concerns, and barriers in the

    Southeastern Pennsylvania region and national landscape. The information these key

    stakeholders offered during the interviews would serve as the framework for the

    design challenge question. In an effort to gain a rich perspective regarding these

    needs and concerns, a multi-disciplinary group of professionals were approached for

    the interviews. As a result, we were able to collect stories and information from

    individuals that represented a wide breadth of knowledge in the behavioral health

    community and included backgrounds in: law, academic, city government, NGO and

    advocate organizations, mental health practitioners, private insurance, and public

    insurance.

    The interview format remained informal to allow for a natural conversation to

    emerge between the interviewer and interviewee. However, an interview guide that

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    included a prepared introduction about the project and a list of question prompts was

    approved by the IRB and utilized for the interviews (see Appendix A). In addition, a

    team approach was incorporated into the process by having a primary interviewer lead

    the discussion while a secondary interviewer listened and took notes. The discussions

    were recorded with the interviewees permission so that the secondary interviewer

    could later transcribe the interview. The final interview was conducted in January

    2012, with the final transcription completed in March 2012.

    Beginning in January 2012, an initial design brief was created that included

    the content for the Design Thinking quadrant of the website. While this brief was

    continuously revised as the project progressed, the initial draft served as a framework

    for the information that would be provided in this section of the website. By February

    2012, this initial design brief draft was released for the project team to review and

    utilize as a reference for the Design Thinking quadrant (see Appendix B).

    3.2.6 Phase 2: Create

    The Create phase of the project was conducted between February and April

    2012. It consisted of analyzing and synthesizing the information collected during the

    Hearphase. The initial goal was to code the data in order to make sense of and

    identify patterns in the information amassed from the key informant interviews. This

    was completed by individual preliminary analyses of interview transcripts where key

    phrases, words, and topics concerning behavioral health were documented. We then

    combined our individual analyses of the transcripts into a classification of key words

    and phrases. In order to verify our combined analyses of the data, the interview

    transcripts were then uploaded into a software program called NVivo, which was

    developed by QSR International specifically to analyze qualitative data. Using the

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    descriptive words identified during the preliminary analyses, a query was run for the

    NVivo program to identify the primary themes, which are referred to as nodes in

    the NVivo software. The output from this query resulted in several themes or node

    categories. The NVivo output was then reviewed to assess the quality of content in

    each node and ensure that the context and classification of each categorization was

    correct. To do so, the output data was compared to preliminary individual data

    analyses to identify any missing references or descriptive words. This information

    was loaded back into NVivo in order to run an additional query. By March 2012 the

    primary behavioral health themes that were identified from the data analyses

    included: public perception, funding, reimbursement, health care reform, workforce,

    integration, recovery, wellness, evidence-based practices, and trauma (see Table 2).

    Table 2. Key Informant Interview Themes

    Note. Represents the number of interviews to mention each theme.

    The secondary goal of the Create phase was to define the opportunities and

    create potential ideas for a design challenge question. This was achieved by

    0 2 4 6 8 10 12

    Trauma

    Evidence-based Practices

    Parity

    Incentives

    Siloes

    Wellness

    Treatment

    Integration

    Workforce

    Health Care Reform

    Reimbursement

    Funding

    Public Perception

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    conducting several brainstorming sessions with the project team during April 2012 in

    order to progress the design thinking from a level of divergent to convergent thinking.

    These sessions evaluated the information collected and began to form distinct and

    concrete criteria for the design challenge.

    3.2.7 Phase 3: Deliver

    Once all of the abstract inspiration and ideas that were collected during the

    Hear phase were synthesized into concrete design challenge opportunities during the

    Create phase, the aim of theDeliverphase was to formulate the design challenge

    model, finalize the design challenge question, and identify the steps needed for its

    marketing and implementation. This process began with the conceptualization of the

    model by the full-time students in which the design challenge would be framed (see

    Table 3). This model encompasses the individual components that are identified for

    the design challenge question and will serve as the framework for its marketing and

    implementation.

    Table 3. Design Challenge Model

    Product Ideas

    ParticipantsAmateur Individuals

    Professional Individuals

    Sponsors Open and Free

    IncentivesRecognitionSocial Value

    Intellectual PropertyParticipant Retain Ownership

    Non-Exclusive License for Challenge Organization

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    To ensure that an active level of interest and engagement was established for

    the design challenge, several marketing plan strategies were devised. A part of the

    marketing plan included a presentation of the project during the 165 th American

    Psychiatric Association National Conference on May 6, 2012. In addition, a Share

    Your Story campaign was expected to be released on the new Scattergood website.

    This campaign would provide a forum where individuals will be able to share

    personal experiences relating to a mental health topic that would be posted on the

    website. Another resource that was identified would be the email listserv of the

    Scattergood Foundation grantees that could receive notifications and periodic updates

    about that the design challenge that could help build awareness and increase the

    number of participants for the challenge. In addition, the power of developing

    partnerships with regional organizations was recognized as a useful tool to build

    support and increase the level of community engagement in the design challenge.

    Several potential design challenge questions were conceived during

    brainstorming sessions in April 2012. Initially, it was determined that the design

    challenge would be posted with the release of the new Scattergood Foundation

    website on May 5, 2012. However, in keeping with the tradition of the design

    thinking as a nonlinear and iterative process, it was questioned whether the

    presentation of the design challenge should be postponed and released on the website

    at a later date. In doing so, the Hear phase of the project would have been continued

    an additional few weeks or months. The implementation of the final Deliver phase

    including the release of the first design challenge would have been postponed until

    late summer or early fall of 2012. This revised implementation plan was the result of

    several meetings and brainstorming sessions where the potential design challenge

    questions were reviewed. During those meetings it was discussed whether there

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    would be a sufficient level of community engagement in the design challenge by May

    2012. In an effort to heighten the level of interest, awareness, and engagement in the

    community about this project, it was proposed that the process of divergent thinking

    should be continued in order to obtain additional feedback from the website users

    about potential design challenge questions as supplemental information to the key

    informant interviews.

    Apprehension regarding the level of community engagement was assuaged

    when the project received an official endorsement from Arthur C. Evans, Jr., PhD,

    Commissioner of the Philadelphia Department of Behavioral Health and Intellectual

    disAbility Services (DBHIDS). In May 2012, he provided the following statement:

    It is important for our field to reframe the issues as behavioral health andwellness, over illness and diagnosis. My experience is that people find itdifficult to talk about mental illness. People are much more receptive whenyou talk about what you can do to be healthy mentally. We need to developinnovative ways to have that conversation. This design challenge is anexcellent strategy for involving the community in our ultimate goal ofimproving everyone's mental wellness.

    In addition, the DBHIDS agreed to serve as a co-sponsor of the design challenge by

    partnering with the Scattergood Foundation to provide consultation and feedback

    throughout the design challenge initiative. During the completion of the Scattergood

    project, DBHIDS was in the process of implementing Mental Health First Aid

    (MHFA) training sessions within the Philadelphia area (DBHIDS, 2012). MHFA is

    an international, evidence-based certification course designed to improve mental

    health literacy (MHFA, 2009). The program provides early intervention training to all

    individuals in order to assist fellow community members who are experiencing

    mental health issues. A key to this program is that it is designed for all community

    members to participate regardless of whether they have a clinical or behavioral health

    background. Trained individuals will be better equipped to recognize, comprehend,

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    and respond to mental health issues or crises. In addition, they will be able to offer

    their services until the crisis is resolved or professional treatment can be administered

    (DBHIDS, 2012; MHFA, 2009).

    To capitalize on this important public health initiative being undertaken by the

    city of Philadelphia, the design challenge goals were modified to include a targeted

    effort to support the MHFA program in some capacity. As of the completion of this

    report, the first design challenge question was not yet finalized. The release of the

    design challenge was due to be implemented by the end of May or June 2012.

    3.2.8 Report Writing

    The report writing process consisted of the full-time students and myself

    synthesizing all of the information we amassed during this project as well as

    recounting our experiences. Throughout my participation in this project I educated

    myself about the subjects addressed in the project including mental health care

    policies and treatment, social innovation, design thinking including human-centered

    design, Web 2.0 and social media, as well as the role of philanthropy as a change

    agent. This was achieved by a literature review that included accessing government

    and NGO reports, journal publications, and media articles about these key topics. In

    addition to my review of the current literature, I recorded my thoughts and accounts

    regarding my participant in the active Scattergood project activities. These activities

    were concurrently completed during my participation as a team member of the project

    between January and May of 2012.

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    3.3 Future of the Scattergood Project

    As with any design thinking process, the search for further advancements and

    improvements is ever present. Thus, the Scattergood Project set a precedent to

    constantly be open to new opportunities in order to consistently grow and evolve from

    their efforts. This is apparent in the decision to revise the implementation plan for the

    design challenge. With the release of the design challenge being postponed, it

    provides an excellent opportunity for future Drexel MPH students to actively

    participate in the implementation and management of the initial design challenge with

    the Scattergood Foundation. The goal is for the collaboration with the Drexel

    University School of Public Health to continue to grow and for future Drexel students

    to assist in the implementation of future design challenges on the Scattergood

    Foundation website. In addition, it is hoped that the support provided by the

    Philadelphia DBHIDS will encourage other partnership opportunities to develop.

    Eventually, it is expected that the winning design challenge solution will be

    implemented within the community. This may serve not only to improve behavioral

    health care in the region, but also set an example for other communities to replicate

    the innovative processes or programs presented in the winning proposal. In addition,

    it is hoped that such initiatives will serve as a foundation for future design challenges

    to be implemented by the Scattergood Foundation. Ultimately, I anticipate that the

    dialogue and opportunities generated from the design challenge initiatives will

    continue to foster innovative and sustainable advancements by the consumers,

    practitioners, and policymakers of our regional and national behavioral health

    systems.

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    4. LESSONS LEARNED

    4.1 Personal Narrative

    Being involved in the Scattergood Project presented an unexpected

    opportunity for me to expand the resources from which I could learn more about the

    current public health systems and issues faced by the Southeastern Pennsylvania

    region and the nation overall. It was also a unique way to absorb a large amount of

    information regarding current behavioral health issues and needed improvements

    directly from some of the foremost service providers and policy makers in the region.

    My unconventional role in the project did result in some personal challenges

    that I needed to address. Perhaps the greatest challenge was adjusting to my part-time

    status in a full-time project. The students with whom I was working were enrolled in

    the program on a full-time basis and thus able to devote much more time to this

    project. Early in my involvement, I realized that my presence and participation would

    be limited by my part-time status in the program and full-time job work commitments.

    For example, I was not able to attend certain meetings or other project activities that

    took place during business hours. I tried to compensate for this by participating in

    any activities that took place during the evenings and, when possible, called into

    meetings and some key informant interviews by phone. In doing so, my goal was to

    demonstrate my dedication to the project while also not committing to more than I

    was capable of providing due to the time and scheduling restraints.

    It quickly became clear to me that I primarily had to adjust to expectations for

    myself rather then my project team members. In fact, my team members were always

    appreciative of any contribution I was able to make to the project and easily

    maintained reasonable expectations regarding my level of participation. Due to my

    personal dedication to the advancement of mental health issues and the reduction of

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    mental illness stigmatization, I found it difficult to not devote the majority of my time

    to this project. However, I knew that it would irresponsible of me to commit more

    time than I was capable of delivering. Therefore, for the benefit of the project and my

    own time management responsibilities, I had to realistically establish what I would be

    capable of contributing. Once these expectations were established and my function

    within the project became better defined, I eventually adjusted to this role.

    Some of the more overarching project challenges identified by my team

    members included adjusting to the application of design thinking methodology. In

    doing so, we had to consistently remind ourselves that design thinking is a nonlinear

    process that may include several iterations of the process as well as its expected

    outcomes. This experimental and non-standardized approach first became apparent

    during the key informant interviews as they were conducted in a conversational rather

    than survey format in order to retain the consumers voice and opinion in our data.

    Ultimately, this led to a richer experience as well as the collection of more compelling

    and valuable information. A few technical challenges were also experienced with the

    utilization of the NVivo program to code the project data. First, the NVivo software

    license only permitted a maximum of two coders. Second, the program was only

    available on one computer, which was located on the Drexel University campus. As a

    result, the program was only accessible during business hours when the building itself

    was open. This was particularly challenging for me since I maintained a full-time job

    during this program and my participation in the project activities were primarily

    conducted after standard business hours.

    My overall experience in this project was primarily an extremely positive one.

    Perhaps the most compelling and unanticipated result of this project experience was

    the beginning inspiration towards a new career path for myself. I entered this

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    program with the general and vague expectation that I would be attempting a career

    change upon graduation. However, during the majority of this program, I had no

    clear idea of what new direction my career path would take. My personal interests of

    mental health and health care as well as my background in clinical research motivated

    me to choose a public health program over business school or public policy-centered

    programs. However I did not yet know how or where I wanted to transition from a

    career in pharmaceutical clinical research. During the course of this program, I found

    myself instinctively drawn to areas of focus that were tied to my personal interests

    while also demonstrating an unmet need as possible opportunities for a meaningful

    contribution to society. I believe that I discovered three areas of interest that fit these

    desired criteria.

    First, the field of public health needs to improve and increase the integration

    of mental health prevention and promotion initiatives into its academic research and

    curriculum, its field-based interventions, as well as its overall frame of thought as the

    field itself continues to gain awareness and a more prominent position in societys

    infrastructure.

    Secondly, the field of mental health needs to take advantage of the increased

    focus on health care reform and utilize this momentum to advance the quality of and

    access to mental health care. In addition, this is an opportunity to further promote the

    integration of mental and physical health care into a unified health care system. By

    participating in such a dialogue, mental health may finally establish itself as a vital

    and integral part of overall health care and wellness.

    Lastly, the increased use of design thinking methods has the potential to

    revolutionize our increasingly fragmented health care system. In addition, this school

    of thought and practice presents an exceptional opportunity to increase the

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    understanding and awareness of mental health issues in our society as well as the

    importance of mental wellness while also reducing stigma. This may just be the

    disruptive innovation that is needed in order to fundamentally shift the way we view,

    address, and discuss mental health concerns.

    Had I followed the path of a more traditional Block VIII project in the form of

    a research paper, I doubt I would have come to these same meaningful conclusions.

    Instead I drew a tremendous amount of inspiration from behavioral health community

    leaders we interviewed as well as the project group discussions with the advisors and

    full-time students concerning topics such as Web 2.0, social media, design thinking,

    and human-centered design to achieve socially innovative solutions. These

    experiences led me to incorporate additional readings about these unfamiliar subjects

    with my previously anticipated research on mental health and health care reform. As

    a result, I feel that my project took a direction that I would not have considered had I

    been left to my own devices while conducting traditional and solitary research for a

    literature review based project. Luckily, I was able to participate as an active member

    of a project team rather than simply as a passive consumer of information. This

    expanded my horizons and opened me up to a new way of evaluating the current

    systemic, policy, and social issues affecting behavioral health care.

    4.2 Future Executive MPH Student Opportunities

    At the inception of this collaboration between Drexel University and the

    Scattergood Foundation, the goal has always been maintained that future MPH

    students could participate in this project as it continues to evolve. Initially, it was

    assumed that only full-time MPH students would participate as a part of their

    yearlong CBMP. However, the opportunity fortuitously presented itself for me to

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    contribute as an Executive MPH student in fulfillment of my Block VIII Independent

    Study requirement. After having completed this project, I can conclude that this is

    may serve as an exceptional opportunity for future Executive MPH students to

    complete