Master's Thesis - Kimberly D. Williams, MPH

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

iii

ACKNOWLEDGMENTS

I would like to thank my advisor, Dennis Gallagher, MA, MPA. The
opportunity for me to participate in this project would not have been possible without
his 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 the
Thomas Scattergood Behavioral Health Foundation for spearheading this project and
initiating the collaboration with Drexel University. His commitment to the
advancement of behavioral health care through collaborative and innovative efforts
has been truly inspiring.

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

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

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

Last but certainly not least, I would like to thank Katherine Carroll and Alyson
Ferguson for graciously allowing me to contribute to their Community-Based Mater’s
Project as a part of my Block VIII Independent Study. Without their steadfast
dedication to the project, this opportunity would not have been possible for me. I am
sincerely 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 years
to 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 Colorado’s Mental Health Care ................................................ 21
2.8.3 “Philanthropy 2.0” ....................................................................................... 23
3. THE SCATTERGOOD PROJECT ..................................................................... 24
3.1 The Scattergood Foundation .............................................................................. 24
3.2 The 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............................................................................................. 36
3.3 Future of the Scattergood Project ....................................................................... 37
4. LESSONS LEARNED........................................................................................... 38
4.1 Personal Narrative .............................................................................................. 38
4.2 Future 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

v

LIST OF TABLES

1. Scattergood Project Timeline (2011 – 2012)........................................................ 26
2. Key Informant Interview Themes ........................................................................ 32
3. Design Challenge Model ........................................................................................ 33

vi

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

2

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 Colorado’s 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 foundation’s 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 no public 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 country’s 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

6

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 state’s 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

Pennsylvania’s public welfare system. Under the state’s 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

10

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 society’s

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 the Diagnostic 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 of inspiration 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 of Viability 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 from Human-Centered Design Toolkit, 2nd Edition by 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). The Hear phase 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). The Deliver phase

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 2012
by 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

19

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 position to 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).

20

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 area’s 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

21

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

community’s 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 Colorado’s 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 Women’s 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 state’s residents. Specifically, they noted that one in

22

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 state’s severe mental health needs,

but only comprise a quarter of the overall state’s 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 Colorado’s

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

Colorado’s 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

23

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 state’s 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

24

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

father’s 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

25

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 Philadelphia’s 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

27

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 project’s graphic designer to build

the new website.

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

students in the Master’s 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 Master’s 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 health
system 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 the
internet.
• Create a question(s) to post on the Scattergood website for the
behavioral health community to discuss and potentially create a
solution 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

28

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 project’s 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. The Foundation

quadrant will provide background and contact information for the Scattergood

Foundation. The Community Impact quadrant 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. The Innovation 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. The Design Thinking quadrant will provide some basic

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

29

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

30

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

The Hear phase 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

31

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 interviewee’s 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

Hear phase. 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

32

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

Public Perception
Funding
Reimbursement
Health Care Reform
Workforce
Integration
Treatment
Wellness
Siloes
Incentives
Parity
Evidence-based Practices
Trauma

0 2 4 6 8 10 12

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

33

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 the Deliver phase 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

Amateur Individuals
Participants
Professional Individuals

Sponsors Open and Free

Recognition
Incentives
Social Value

Participant Retain Ownership
Intellectual Property
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 165th 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

35

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 and
wellness, over illness and diagnosis. My experience is that people find it
difficult to talk about mental illness. People are much more receptive when
you talk about what you can do to be healthy mentally. We need to develop
innovative ways to have that conversation. This design challenge is an
excellent strategy for involving the community in our ultimate goal of
improving 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,

36

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.

37

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.

38

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

39

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 consumer’s 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

40

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 society’s

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

41

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

42

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 their Block VIII project and one that is ideally suited for someone who is

considering a career change or advancement after graduation. The aspects of this

project afford students the chance to meet many prominent professionals in the local

behavioral and public health communities. One is not as likely to receive this level of

exposure when completing the relatively solitary task of writing a traditional research

paper. By virtue of collecting qualitative data from behavioral and public health

professionals and implementing a design challenge with the same target audience in

mind as participants, future students may have several opportunities to engage with

such professionals on a remarkable level.

Since I believe students of public health should include behavioral health in all

aspects of their education, I may be biased in my willingness to promote working on

project that directly addresses behavioral health concerns of the region. However, it

is my opinion that the in-depth focus on social innovation and the usage of design

thinking techniques in this type of project will add a unique perspective and

unparalleled learning experience for Executive MPH students. I believe that the

application of design techniques to achieve socially innovative solutions is a

discipline that is still evolving and has yet to reach its full potential, particularly in the

field of public health. Therefore, this may serve as an ideal setting for Executive

MPH students at Drexel University to “get in on the ground floor” so to speak, expand

their skill set, and enable their public health career to advance in an exciting direction

they may have not previously considered.

43

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Master's Thesis - Kimberly D. Williams, MPH

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