LDI Health Policy Seminar Series
2001 Charles C. Leighton, MD, Memorial Lecture

Estelle Richman

Director of Social Services for the City of Philadelphia
(former Health Commissioner)

"Vulnerable Populations in American Health Care"

November 9, 2001
2:00 - 3:30 p.m.

Room 211, Steinberg Hall-Dietrich Hall (3620 Locust Walk)

Summary Biosketch

On November 9, Estelle Richman, Managing Director for the City of Philadelphia, and Former City Director of Social Services, began LDI's seminar series focusing on vulnerable populations. She used the television series "Survivor" theme to highlight the challenges faced by clients trying to navigate the city's fragmented health and social services systems. She noted that the current systems provide acute care very well, but fail to meet the long-term needs of individuals they serve.

"We need to ask…where does the person want to be, and are we helping him or her fulfill that dream?" Ms. Richman said. Too often, she noted, each service provider focuses only on one aspect of a person's being, thereby ignoring (and sometimes exacerbating) serious problems outside of the provider's expertise but critical to the well-being of the client.

Ms. Richman presented the real-life saga of a person in the Philadelphia health and social services systems from age seven to adulthood. The individual had to "survive" multiple contacts with Child Welfare Services, the Juvenile Justice system, acute care health facilities, the Behavioral Health system, and the Mental Health system. Each system provided the acute care she needed, but failed to address her longstanding emotional needs, often labeling her as noncompliant. The individual, whom Ms. Richman later introduced to the audience, managed to succeed in spite of the systems designed to help her, not because of them.

This example illustrated the necessity and urgency of changing the paradigm of service delivery. The various health and social service providers currently function as independent "silos," that do not communicate or collaborate with one another. "Too many individuals fall through the cracks" in the current system, Ms. Richman said. The challenge is to break down these "silos" and integrate service delivery.

Ms. Richman outlined three requirements for integrating services: coordinated, collaborative case management, shared data systems, and good outcome measures. First, she noted, service providers need to work together to ensure case management efforts do not overlap or contradict one another. Services need to be provided across the "silos" that currently act independently. Second, data systems must be able to communicate so that information is available across agencies and departments. Ms. Richman said that the biggest barrier to shared data systems is the need to protect confidentiality. Although she acknowledged the importance of confidentiality, she also stated that, "I don't want people dying with their confidentiality intact." Third, Ms Richman pointed to the need for measurable outcomes to be articulated across systems of care. Providers must develop measures, establish qualitative outcomes, and continually strive to improve those outcomes. Qualitative assessments of the effectiveness of services, as given by the clients themselves, are key outcome measures.

Ms. Richman acknowledged barriers to change within bureaucracies. Change will not occur, she said, until we recognize the status quo as unacceptable. Once that decision has been made, both a top-down and bottom-up approach must be implemented. Management, as well as front-line workers, must be involved in the change efforts. Opportunities to pilot new ways of providing services must be taken, and every "bad" outcome needs to be analyzed for possible points of intervention.

In meeting with agency heads, Ms. Richman challenges them to reflect the values embedded in their missions in their work with clients. She encourages them to shift the focus from counting units of service to assessing the quality and outcome of services. Ms. Richman envisions the creation of a more holistic and user-friendly approach to service delivery as the mission of providers. Such an approach must involve integrated systems and a seamless provision of care. The goal, she said, is for clients to "survive" the system automatically, and for success stories to become the norm.

She ended the lecture by communicating several "lessons learned" in her years working with people in human services:
1. Focus on the person, not the policy.
2. Permit individuals to "get a life." Remember the clinical point of view is not always the right     perspective.
3. Allow success because of the system, not in spite of the system.
4. Never underestimate the power of the human spirit to survive.

Ms. Richman's presentation was also the 2000 Charles C. Leighton, M.D. Memorial Lecture. The annual lectureship, made possible through an endowment from the Merck Company Foundation to the Leonard Davis Institute, honors the memory of Dr. Leighton, former Senior Vice President, Administration, Planning and Science Policy for the Merck Research Laboratories. Each year, the lecture brings together policy makers, corporate leaders, researchers, students, and faculty for substantive discussion on leading health policy issues.

Ms. Richman brings more than 25 years of public service to her role as the Director of Social Services for the City of Philadelphia. She was appointed to the position by Mayor John F. Street on January 18, 2000. Under Ms. Richman's direction are the following City Departments: Public Health, Human Services, Behavioral Health, Mental Retardation Services, Special Needs Housing, Recreation, Prisons, Anti-Graffiti, Mural Arts, Mayor's Office of Community Services, and Mayor's Commission on Disabilities.

As Health Commissioner for the nation's fifth largest city, Ms. Richman headed a department of more than 1,300 employees with an annual budget of $953 million in federal, state and local funding.

Among Commissioner Richman's achievements is the restructuring of the Philadelphia region's AIDS services system, making the level of consumer participation in that system the highest anywhere in the nation. She managed the privatization of the Philadelphia Nursing Home, and established the Office of Behavioral Health Services in the Health Department. As a member of the Mayor's Children and Families Cabinet, she has collaborated with families, public and private agencies, neighborhood organizations and groups, to create family centers, youth access centers, and anti-violence initiatives.

A nationally recognized expert on issues of behavioral health and children's health, Ms. Richman has been honored for her advocacy efforts by the Alliance for the Mentally Ill, the American Psychiatric Association, American Medical Association, among others. She is also the recipient of the 1998 Ford Foundation/Good Housekeeping Award for Women in Government which recognized her role in creating a non-profit organization established by a City government to oversee Medicaid managed behavioral health care. In addition, the Behavioral Health System was named a winner of the 1999 Innovations in American Government Grant Award, given by the Kennedy School of Government, Harvard University.

A former Deputy Health Commissioner for Behavioral Health, overseeing the Office of Mental Health, the Office of Mental Retardation, and the Coordinating Office of Drug and Alcohol Abuse Programs, her responsibilities included fiscal, clinical and programmatic management of these areas. Prior to this, she was Southeast Area Director for the Office of Mental Health within the Pennsylvania Department of Public Welfare and had the primary responsibility for the closing of Philadelphia State Hospital.

Ms. Richman came to Pennsylvania after many years in Ohio. There she was the Executive Director of the Murtis H. Taylor Multi-Services Center, a comprehensive multi-service agency. She was also Assistant Director with the Positive Education Program, a comprehensive day treatment program for children and adolescents.

Ms. Richman received her MA in clinical/community psychology from Cleveland State University in 1976.

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