Weaving change. Weaving chances to change. Weaving is the process of combining warp and weft components to make a woven structure
In 2001 Carlene Donnelly began work with a small Alberta non-profit, CUPS Calgary, providing frontline services to some of the city’s most vulnerable residents.
Early on the Vernon River native recognized clients were forced to repeat their complex stories, often involving trauma, at every step in accessing services. Donnelly identified 13 separate CUPS entry points, for everything from housing to mental health and addiction treatment, child family services, legal, and healthy relationships.
No one was looking after the clients’ bigger picture. She knew there must be a better way. After being named CEO in 2003 she set about redefining how frontline services are delivered, while growing CUPS into a multi-million-dollar, silo busting, non-profit, unlike anything in PEI.
If there is anyone capable of weaving together disjointed and seemingly disparate care efforts into a well-coordinated, client centred teamwork – Carlene Donnelly is it. She’s already done it.
Among other accolades, CUPS was named one of Canada’s top 10 Canadian Impact Charities by Charity Intelligence Canada four years in a row, 2017 through 2020 under her direction. The award recognises efficiency and innovation.
PEI talks of co-ordinated, client centred care. In many ways the Island’s social services system is where CUPS was more than a decade ago. Clients bounce around service to service, repeating their stories. Sometimes they access redundant support, other times they leave an inappropriate service frustrated while a solution may exist next door. A chronic staffing crisis in Child and Protective Services means that clients often are forced to repeat their stories to a new social worker. It can occur multiple times.
And that’s just one area of government.
“What I love about it is that we did build our entire program, really on the science,” said Donnelly who speaks with a rapid-fire delivery streaming together insight, analysis, data points and corporate strategy – often in a single breath.
Every client entering CUPS is taken through a 40-minute assessment called the integrated care assessment tool, a questionnaire developed by CUPS in partnership with the University of Calgary Faculty of Nursing. Data from Harvard University Centre of the Developing Child, which CUPS has a partnership with, and Alberta’s Palix Foundation were instrumental in its creation.
“It’s not a formal clinical tool, but it gives us enough information to know what the priorities are to at least start a care plan with that person,” she says. The tool assesses a client’s strengths and weaknesses and potential capacity to face adversity.
Donnelly says clients often experience epiphanies when they recognize that their mental health or addictions are a predictable side effect of adversity, such as childhood trauma.
“It is incredible to hear their stories, because they will say to you, I thought I was just a screwed-up person or a mixed-up person.” she says. “It is the first time in many ways, and I hear this all the time, they feel forgiveness for themselves.”
These epiphanies, paired with an evidence-based plan showing how an individual can make lasting change, is powerful motivation. “So they do the work. They show up and do the work.”
The intake session provides clients with a one-stop-shop for accessing all potential entry points of service. Services, whether delivered directly by CUPS or a service provider the organization partners with, share the same client information.
It’s the type of simplified entry point and co-ordination that PEI can only dream of, with its labyrinth of disconnected programs and services. While PEI nibbles away at the edges of systemic change, Donnelly’s created the technology and processes that could allow PEI to quickly make a massive leap forward into current best practices.
To her, everything is interconnected. Housing. Mental health and addiction. Family. Childhood trauma. Education. Employment. Transportation. Without effective, comprehensive, and interconnected intervention, she contends, issues become generational.
When these are disconnected, it creates a primary impediment to delivery of impactful programming.
Donnelly earned an undergrad at UPEI with a major in psychology, a Masters of Education from UNB, and a Master’s in Business Administration from the University of Phoenix. She recognizes that no organization – government, non-profit or community – can do everything. When a range of players with different expertise co-ordinate and contribute to the same cause it can be massively beneficial.
CUPS was born in an era of austerity when the Alberta government offloaded frontline services to non-government organizations. Today it employs 200, including: doctors, nurses, psychiatrists, counsellors, care coordination specialists, and educators. Half of its annual $18 million budget is fundraised through corporate donors. Donnelly says this funding is achieved thanks to extensive community engagement campaigns.
But if history is any guide, adopting a new service model might be a difficult sell to both health care workers and the public. The key, Donnelly says, is for all partners to know what their strengths are, and engaging the right solution at the right time. Transparency is imperative. She talks often of ‘knowing where your lane is’ and views CUPS as supporting, not competing, with other service providers.
She believes street level service providers, tied to non-profits or other community programs, are best able to meet the needs of complex mental health and addiction populations.
“We do better at the service level and community level, creating a care plan for them that is not just picking them up and taking them to a detox or to a shelter or to emergency department.”
Other players have important roles too, such as government’s oversight of funds.
“If we can respect where each other’s expertise stop and start, right there and then we have more of a coordinated service,” she says.
Meaningful data sharing is key to any effort at change. It’s an idea that is talked about, but not implemented here.
“Health systems improve when they monitor and evaluate what is being done, and openly share better ways of doing things,” states PEI’s 2016 Mental Health and Addiction Strategy, which set out an ambitious roadmap for improving the level of care over 10 years. “Improvements and innovations are maximized by good quality, well organized data that makes it possible to identify and respond to the diverse needs of specific populations with targeted services and supports,” the report states.
But the vision of an interconnected, responsive system has gone largely unmet, with little evidence of cooperation or coordination between government departments and agencies, specifically as it relates to the sharing of data.
Solutions proffered involve creation of phone lines to tell people where to go, a system those with lived experience say is of little benefit. Navigators are hired to send clients to the front door of services, but there is little data to track results of these interventions.
With access to clear data, not only is CUPS better able to direct clients to appropriate services but the organization is able to identify and fill gaps in care.
“What I have done is say where do the services of, let’s say Health PEI, stop and start and for what population? And for what needs, then how do we complement that and actually become an asset to you. This isn’t a competition,” she says.
Through the Cracks is a one year investigative effort by The Eastern Graphic, West Prince Graphic and peicanada.com to put a face on PEI’s mental health and addictions crisis. We introduce you to those impacted, outline the issues and propose potential solutions. This is the largest editorial effort in Island Press Limited history and potentially Island history.
More from this special report
Donnelly uses the example of a man who visited the emergency room 36 times the previous year. CUPS has built relationships with three Calgary area hospitals so when a person arrives who does not need medical care but has nowhere else to go, CUPS is called.
CUPS was able to provide the individual a short-term housing solution in a shelter, which grew into a full-time apartment. The client has lived there for more than a year. It is a system that provides far greater supports at significantly less cost than ER visits, Donnelly says.
Donnelly added that service follow up data would be particularly beneficial to rural areas such as PEI. Research shows that rural areas have distinct cultures that affect what services are most beneficial and how solutions are tailored to serve the population.
“They need to have a voice and a platform to talk about the needs of that particular community. They really do,” said Donnelly. “And that is something that people have to understand. If that isn’t led by the community, no matter what government or any other resource tells them, it’s not going to be as effective.”
While Donnelly says CUPS is not perfect, it is effective at providing necessary intervention and programming to individuals, families, and children, with the added benefit of helping to prevent generational issues.
“It is a work in progress that is increasing coordination and navigation to the better. We are far from perfect. There’s still lots of cracks and issues. But the conversation continues with the right people at the table.”