Report date
February 2020

What has been most instrumental to your progress?

Insights gained from extensive discussions with over 30 local stakeholders were instrumental to (a) identifying DSY as the priority population and (b) narrowing the wide array of potential behavioral health interventions that would be most effective and appropriate in North Dakota, based on the unique state context and constraints. Telehealth and school networks were a few ideas identified through these conversations, both of which were being tested by a few existing service providers and are creative solutions for addressing challenges related to geographical coverage and human resources as part of a pilot PFS program.

Complementing the stakeholder interviews with rigorous analyses of the literature and evidence allowed us to generate a comprehensive list of potential interventions. This dual-approach provided us the knowledge base and local context necessary to narrow in on the best suite of interventions to achieve the intended outcomes.

Though all the project design parameters are closely linked, using a similar approach, we triangulated a set of reasonable options through the two key activities above, which we then took to stakeholders for their reactions.
The Department of Corrections & Rehabilitation (DOCR) and Department of Human Services
(DHS) are potential outcome payors and have indicated preliminary interest in identifying funding within their existing budgets to pay for improved outcomes for dual status youth, likely in the range of $2-6M.
• Next steps would be contingent on payor commitment and funding availability and would focus on:
(i) refinement of key project design parameters, based on local data, (ii) service provider(s) capacity assessment, and (iii) development of the financing structure, including raising private capital (as needed) and structuring the vehicle for outcome payments

Key lessons learned

Cultivating strong local relationships across a broad range of stakeholders (e.g., executive, legislative and judicial branches, across government agencies, and service providers), especially at the leadership level, can yield positive dividends in unexpected ways. For example, we engaged a member of the Blue-Ribbon Panel (head of Juvenile Court Services and the Dual Status Youth Initiative) at a convening introducing Pay for Success (PFS) and soliciting preliminary feedback on project design. The Panel member later helped provide key pieces of data and facilitated requests to the Court. Subsequently, his move to the Division of Juvenile Services in the Department of Corrections & Rehabilitation (DOCR), then the Division of Children & Families within the Department of Human Services (DHS), has created an important point of continuity across agencies. In North Dakota, relationships are key and talent often moves among various stakeholders.
In hindsight, we should have prioritized building stronger relationships with the Court system. The Project successfully leveraged ThinkND’s strong relationships with DOCR and DHS. However, although DHS and DOCR serve Dual Status Youth (DSY), the Court system is an integral stakeholder given they engage with the population on the front-end of the juvenile justice process and they hold access to the data needed to finalize key project design terms. Recognizing the centrality of data to PFS, lack of a champion among Court leadership (despite engagement with Tribal and District Courts) led to prolonged delays to data. While this did not hinder the project during the initial design phase, this gap has proven more challenging in the implementation phase, especially after DOCR expressed willingness to cultivate other agencies to take on a greater leadership role. However, there is a window of opportunity now with the naming of a new Supreme Court Justice to change this dynamic and galvanize cross-agency collaboration.

Reflections on inclusive, collaborative or resourceful problem-solving

Response: The “inclusive” element of the community innovation process, which spanned agencies, sectors and functions, both within the behavioral health space and related to dual status youth, catalyzed insight into project design. Inclusivity has two directions: receiving key community input, but also investing in helping the community understand and buy into the proposed innovation, in this case, PFS. In this project, inclusivity helped build trust and credibility, leading to stronger collaboration (and willingness to take more ownership) across agencies and stakeholders, an important outcome itself in the development of PFS projects. In turn, greater ownership and understanding of PFS has led to better utilization of existing resources, for example, creating flexibility within existing funding (for adults) through Legislative action to serve dual status youth.

Finally, including the viewpoints of the community means better understanding the existing resources that could be tapped. It also best positions the project to work effectively in the North Dakota context, for example, through using existing service provider organizations, interventions.

Other key elements of Community Innovation

It also best positions the project to work effectively in the North Dakota context, for example, through using existing service provider organizations, interventions (including valuable local adaptations to those interventions) and service delivery network. The diverse local network and deep relationships that ThinkND has provided acritical backbone for amplifying community innovation.

As noted above, having a strong framework to develop the innovation (in this case, PFS), including a robust methodology and criteria for evaluating evidence, helped foster a collaborative decision-making process that was vital to making progress on the project’s objectives. It was incredibly helpful to have an expert partner in Social Finance who was able to bring a framework, as well as experience doing this in other communities, to the table, which helped accelerate alignment across multiple stakeholders.

Understanding the problem

This work helped prioritize and segment the need. Building on the shared understanding among experts (the Blue Ribbon Panel) and local stakeholders (over 30 interviewed) and conducting an exhaustive evidence scan, the project partners matched services to the target population that would most benefit -- namely dual status youth (youth involved in both child welfare and juvenile justice systems), including at-risk and Tribal youth, in Bismarck, Morton and Sioux counties. The work generated ideas on key project parameters, including priority outcomes and potential interventions, based on an evaluation of need, evidence and data availability, among other criteria. Further clarity emerged on how solutions would need to be tailored to ND’s unique context and challenges; specifically, the concept of delivering a “suite” of services (vs. a single intervention) on a spectrum of intensity, including wraparound support (not only “therapeutic” interventions), as the preferred approach to improve behavioral health outcomes in ND .
A summary of the proposed project blueprint (Slide 3), including preliminary hypotheses and rationale, can be found in the Final Project Compendium attached.

If you could do it all over again...

Make sure to engage the Supreme Court early to promote greater buy-in and understanding of PFS, potentially through the Dual Status Youth and Court Improvement Initiatives. This would have brought all three state entities touching dual status youth (Courts, DHS, DOCR) to the table and unlocked data necessary to drive implementation.

One last thought

Prior to this grant, ThinkND, through extensive community engagement, had broadly identified behavioral health as a top concern for North Dakotans. A shortage of financial and human resources, as well as limited understanding of evidence and data, were identified as key drivers behind the systemic underinvestment in behavioral health interventions. Through the Community Innovation Grant, ThinkND partnered with Social Finance to explore the feasibility of Pay for Success as a promising and innovative financing mechanism that could more effectively and sustainably leverage existing public resources and bring together partners across sectors to address service gaps.

Finally, extensive engagement with DOCR and DHS led to the successful introduction of Legislative language to allow flexibility in existing budgets (the Free Through Recovery program) to pay for improved outcomes for dual status youth, paving the way for funding a potential first Pay for Success pilot in North Dakota.