TeamWork: Leadership for Healthy States

CASE STUDY

VERMONT
2015-2016

Team Members:

Tracy Dolan*
Honorable Claire Ayer
Hal Cohen
Honorable William J. Lippert
Robin Lunge
Honorable Virginia Lyons, Ph.D.
Ken Schatz
Beth Tanzman
Honorable George Till, M.D.

* Team Leader

For additional information, contact:

Tracy Dolan
Deputy Commissioner
Vermont Department of Health
Phone: 802-951-1258 | Email: Tracy.Dolan@state.vt.us

The TeamWork: Leadership for Healthy States programpreviously known as the Excellence in State Public
Health Law Programstrengthens relationships within and across branches of government, builds
understanding of population health issues, and opens channels of communication and problem-solving that can
be used to address future population health challenges.
The Health in All Policies Vision

The five key-elements of the Health in All Policies (HiAP) concept are: promoting health and
equity, supporting intersectoral collaboration, creating co-benefits for multiple partners,
engaging stakeholders, and creating structural or process change. Teamwork: Leadership for
Healthy States provided Vermont with an opportunity to continue to explore HiAP as a
framework to prevent and mitigate Adverse Childhood Experiences (ACEs) and to improve the
health of Vermonters. The program came at an opportune time in Vermont, as it coincided with
the Governors Executive Order in August of 2015, appointing a Health in All Policies Task
Force to coordinate across agencies around issues of healthy communities. The Task Forces
cross-sector composition positions it to optimize collaboration among state agencies that are not
focused exclusively on public health, but whose decisions have important consequences for
health outcomes and health care spending.
ACEs encompass traumatic experiences occurring during childhood and adolescence such as
child abuse, parental divorce, family violence, parental psychiatric and/or substance abuse issues,
absence of basic care, abandonment, deprivation of food or shelter, and lack of encouragement
and support. With a growing understanding of Health in All Policies, the team decided to focus
its deliberations on ACEs to address both the current challenges facing children and the long-
term health and social impacts (such as poor academic achievement and financial stress) that
ACEs can have. The cumulative effects of multiple adverse childhood experiences have
profound public health and societal implications. ACEs can damage neurobiological and
neuroendocrine functioning, affecting behavioral, emotional, social, physical, and cognitive
development. These effects may contribute to the development of chronic medical conditions
and psychiatric illness in adulthood.
Awareness of the effects of ACEs has been increasing in Vermont in recent years, and legislators
and state leaders have expressed interest in trying to address ACEs in a systematic way. Vermont
has witnessed the impact of ACEs through the rise in caseloads in the Department of Children
and Families; through the acceleration of the opioid epidemic, which is both driving and being
impacted by family breakdown; and through rising health costs associated with adult chronic
illness. A review of the health system studies on preventing ACEs commissioned by the
Vermont Legislature found that the most effective programs those that increase healthy family
relationships, improve parenting behaviors, and decrease rates of child abuse and neglect share
core elements and content.

Project Summary

The Vermont teams goal has been to improve health by preventing ACEs and to provide timely
support for families. Following the opening TeamWork retreat, the team convened four times via
teleconference and once for a half-day in-person session in April 2016, to plan a community
inquiry and engagement strategy. It subsequently reviewed the findings of the community
inquiry sessions and agreed to develop a core set of recommendations for policy makers.
Notably, the team has remained committed to continuing this work beyond the TeamWork

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programs conclusion, and it aims to develop a more expanded set of recommendations than
what it completed by the end of the project.

During its first few months together, Team Vermont discussed several strategies to prevent and
mitigate ACEs, and after the first cohort meeting it developed a short list of possible strategies
including home visiting, mental illness and substance abuse treatment, and parenting training
programs. To narrow the focus and choose an achievable goal, the team relied heavily on the
evidence base for what works in preventing ACEs and considered what was already happening in
the state. A variety of home visiting programs in Vermont, including recently expanded
programs (such as the Nurse Family Partnership) have proven results in preventing ACEs, with
the strongest impact being a decrease in child maltreatment. This was the foundation upon which
Team Vermont built.

VT Teamwork, in This group is uniquely

LEVERAGE / ADVANTAGE
KEY STRATEGY

Improve Health by
BIG GOAL

preventing Adverse consultation with child positioned to promote public

Childhood Experiences development experts from policy and practices.
(ACEs) and providing the State and with the
timely support for Home Visiting Alliance,
decided to concentrate on As of July 2016, VT Teamwork
families.
a strategy that maximized succeeded in these goals:
the impact on the child 1) Sustaining the current home
and family. visiting programs for at-risk
Make evidenced-based / moms, and
informed home visiting 2) expanding the capacity for
available to all pregnant evidence informed home
women and continuing to visiting.
age three.

Recommendations on the expansion of home visiting were informed by team discussions, input
from experts on home visiting in Vermont, and discussions with key informants, stakeholders in
two communities, and the Home Visiting Alliance.

The broader goal required a more comprehensive approach, so Team Vermont agreed to continue
its work beyond the TeamWork programs one-year duration.

Over the course of the project, no lobbying took place with Robert Wood Johnson Foundation
funds.

Cross-Sector Collaboration

In Vermont, state leaders and legislators have been particularly focused on improved outcomes
as a focus area for health policy. Across the state, leaders have been educated on the Results-
Based Accountability framework and have instituted such a framework in our laws and in our
state measurement systems.

When selecting members of Team Vermont, participants were invited based on interest, ability to
influence outcomes, representation of diverse voices in leadership positions in state government

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and within the legislature, and expertise in health and human services. The team included a mix
of people who are innovators (particularly the legislators, people who are experienced in systems
change, and leaders who have a strong understanding of the established systems into which
innovation can be introduced). The team itself was an exercise in building new partnerships.
While different team members have worked together on a variety of issues, this configuration of
state and legislative leadership had not worked together on one initiative. The teaming resulted in
new connections, which fostered stronger partnerships between the Department for Children and
Families and the Department of Health, between legislators and early childhood leaders across
the state, and between state and legislative leaders who care about children, families and
improved health.

TeamWorks requirement that Vermont include as team members both legislators and leaders
from state government was pivotal, and deepened the commitment of key state-level decision
makers. Representation from the Governors office brought his perspective to the project and
assisted with the teams understanding of the complexities and possibilities of funding an
expanded home visiting infrastructure in Vermont. Legislative team members kept the team
grounded in the realities of what their constituents want and need and in the importance of
engaging local leadership and tapping into local knowledge.

The Benefits of TeamWork

TeamWorks technical assistance funding allowed Team Vermont to engage a strategic thinker
to help map out a process. It also enabled the team to develop a short video
(https://www.youtube.com/watch?v=cQnjvqxektQ) designed to educate legislators and other
state decision makers about home visiting, its impact on families, and the connection between
ACES and early interventions like home visiting. The most valuable resource provided through
the TeamWork program was the time that was set aside for the eight team members to sit
together, share philosophical frameworks, talk about the challenges facing Vermonts families,
review a situational analysis of the resources that exist in the state, and determine what would be
achievable as a group over the program period and beyond. Team Vermont looks forward to
meeting in the coming months and years to continue its work and to expand partnerships and
strategies to prevent and mitigate ACES in Vermont.

Participation in the TeamWork program also led to several key findings and policy
recommendations:

Availability of evidence-based early home visiting programs can benefit all families in
Vermont from low risk families who need a less intensive intervention to higher risk
families who would benefit from a more comprehensive program like the Nurse Family
Partnership.
Communities already invested in programs to mitigate ACEs are concerned that universal
access could supplant existing funding for current programs. In Vermont, the Agency of
Human Services is partnering with Harvard University to explore a pay for success model
that may be able to support expanded home visiting.
Existing evidence-based programs not designed for high risk families can still have
significant impacts on reducing risk for children and their parents.

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 The existing structure being used for referral works, but may need to be scaled if home
visiting is to be expanded, resulting in an increase in the volume of family referrals.
Communities want to deliver quality programs but need support, specifically training and
supervision in evidence-based home visiting programs. Current programs do not
consistently reflect high quality home visiting practice.
Home visiting is not normalized as a source of support in pregnancy and through early
childhood. Stigma could limit uptake of this important resource.
The benefits of home visiting programs are becoming better known and there is a need
for an evaluation framework that will show both effectiveness and cost.