Collaborative Governance in State-Wide Behavioral Health Reform Implementation

Background and Purpose: States are transforming public behavioral health systems at a large scale and rapid pace. When structural reform occurs simultaneously across regulatory, management, payment, and delivery systems, the likelihood increases that implementation setbacks will occur. If unaddressed, unintended consequences negatively impact service quality and accessibility, worsening health disparities for medically, socially, and economically vulnerable populations. This study examines one state’s effort to use a collaborative governance regime (CGR) as an instrument for implementing comprehensive behavioral health reform. Collaborative governance is an increasingly popular policy tool that engages public and private stakeholders in shared decision-making. To understand how a CGR can be used most effectively in the implementation of public policy it is necessary to understand the objectives stakeholder groups bring to it, their experiences of the process, and whether meaningful differences exist among groups. This study asks two related questions. What were participants’ priorities for the CGR and how do they vary by stakeholder group? And how did they perceive the value and challenges of their involvement?

Methods: Researchers partnered with CGR leadership to create a survey that included Likert-type ratings, categorical measures, and closed-ended questions. The survey was administered to all CGR participants in three waves at six-month intervals over a one-year period with a total n=214. 100 percent of eligible participants completed it. Analysis of Likert-type measures included descriptive univariate and bivariate analysis, comparing means across stakeholder groups. Open-ended survey questions were managed using Dedoose qualitative software. Data were coded using deductive schemes by two coders over four cycles.

Results: Six stakeholder groups comprised the CGR: peers, family, and youth (PFY); community-based organizations (CBOs); hospitals and health systems (HHSs); managed care organizations (MCOs); local government officials (LGOs); and key partners (KPs). All stakeholder groups ranked improving access to services and improving service coordinationas their highest priorities. PFY, HHSs, MCOs, and KPs ranked knowledge-sharing as the third highest priority followed by developing best practices. CBOs and LGOs ranked developing best practices a higher priority than knowledge-sharing. All stakeholder groups ranked improving technology as the lowest priority. In open-ended prompts, participants’ written priorities clustered into three main codes: reducing barriers to access; improving reimbursement processes; and clarifying processes related to managed care reforms. They valued participating in the CGR for knowledge development, peer support, communication across groups, and collaborative problem-solving. And they perceived primary challenges in the CGR related to meeting logistics, representation, comprehension of detailed information, and overall impact.

Conclusions and Implications: In an era of sweeping behavioral health policy transformation, collaboration across systems is increasingly important to ensure the success of implementation. This study systematically analyzes the priorities behavioral health stakeholders bring to a CGR and provides insight into their experiences of value and perceived challenges in the process. By highlighting important continuities and differences among stakeholder groups, this study establishes a framework for understanding the challenges stakeholders observe in the policy environment and illuminates how collaborative governance may help to improve implementation, reduce unintended consequences, and better serve the vulnerable populations public policy targets.