Through a community-based planning process, the Northern Michigan CHIR developed a proposal to MDHHS for funding to improve the way that health and behavioral health serving organizations interact with the homelessness service sector to make sure that patients have safe discharge options when exiting any healthcare service, and don’t fall through the cracks. 

The overarching project related to this proposal develops a human centered service design process that informs discharge policies, including a visualization of:

  • How people move through the health and behavioral health systems,

  • Information typically provided at each point of service, and

  • Responsibility for hand-offs from the health and behavioral health providers to the homelessness service system.

We’ve also done qualitative and quantitative research to better understand the constraints and opportunities on each side, so that together we can develop shared language, enhanced communications strategies, and cross training.

Within and beyond this primary project there were specific model discharge policies and procedures developed through pilots in healthcare discharge at Munson Hospital in Cadillac and in behavioral health with Addiction Treatment Services (ATS) in Traverse City. This document outlines the process taken to develop these changes so that any organization interested in replicating these projects will understand how best to move forward.


In order to have the discussions that will lead to policy and procedural changes, the people who can make those changes need to be in the room and need to be willing to accept the limitations of the ways things are currently done and be open to brainstorming improvements. Since it is most likely that there will be cross-training opportunities identified, the people who would both provide and supervise those receiving it need to be involved to inform that process. The objective is to engage participants that are close enough to the clients being served, who have intimate knowledge of clients attempting to move through the systems so that they can tell the stories of those clients and where the systems succeeded and failed.

These invitations need to be equalized from both sides of the service system intended to change policies and procedures. The assumption is that one side is the homelessness service system and the other the organization(s) targeted for collaborative improvement. It’s critical to recognize the importance of creating an open forum for discussion that doesn’t assess blame or responsibility but relies on a joint responsibility of all parties to create the best client experience possible within the constraints of all of the programs and services involved. Everyone should come into the project understanding that each person there can do better than they are doing now, and by sharing knowledge will be able to brainstorm relevant, actionable solutions. The limitations are most likely not personal, but policy and procedurally limiting and that they are in the room to identify the ways that those policies and procedures can change to improve the client experience.

To ensure the discussions and processes moving forward, there needs to be both a process Facilitator and Scribe. The Facilitator creates the agendas, convenes the meetings, facilitates the discussions and rechecks at the end of each session to make sure that the process stays on track. The Scribe is not a note-taker, but listens for and records specific information to identify gaps in hand-offs and larger systems.

The Process 

Meeting 1: Storytelling 

Begin the process of discovery by introducing the concept of storytelling as a way to identify gaps and opportunities in service delivery and coordination. As stories are collected, the Facilitator, Scribe and participants are welcomed to ask clarifying questions. Together, participants build an understanding of the challenges experienced by both clients and workers in each area.

The Scribe has the role of outlining the places where the client either is or could be handed off to services from the homelessness system or back to the other system involved in the project. As an example, there may be an occasion where it would be helpful for the client to be turned over to the homelessness service system, but if the other system isn’t asking about the client’s housing situation that hand-off cannot occur until it becomes apparent through some other interaction; or it may never happen at all leaving the client without any connection.

Once the possible hand-offs are identified, the solutions for filling the gaps are easier to see as opportunities for procedural and policy changes. As a follow-up to this meeting, the Facilitator, Scribe, and the policy/procedure makers from each system hold a meeting to delve more deeply into the specific changes that might be made to improve the client’s experience in light of the identified hand-offs.

If possible, including clients in separate conversations is critical to understanding the barriers, not as practitioners see them but as those who receive the care see them. As in our larger project, it may be necessary to meet with clients separately from the meetings proposed above.

This is a sample of the Scribe’s output

This is a sample of the Scribe’s output

Meeting 2: Service Design 

Bring the visualization(s) back to the group and verify that the stories previously collected are accurately depicted: phase by phase, with the individuals and organizations that were a part of the process for each specific client. Then engage in the “how might we?” discussion as the group brainstorms ways to better connect the systems to the client. Understanding that extraordinary measures are often taken to safely house clients, the goal will be to bring forward the experience of the “outliers” – those who have successfully navigated the system despite its barriers – and see if there are ways to replicate those successes for the majority of clients.

Sample Service Design visualization in Microsoft Excel

Sample Service Design visualization in Microsoft Excel

Meeting 3: Proposed Solutions

Based on previous conversations, hypothesize ways for individuals and organizations to partner more closely to fill identified gaps. Using the visualization(s) as the baseline “landmark(s),” trace the pathways of various clients through an improved system, noting where handoffs might be more effectively accomplished. Discuss these as a group so that feedback is incorporated into the understanding and experience in the final design discussion.

If there are organizational policies that are getting in the way of better client services and connections, the people who are able to make those policy changes are charged with working toward that end. If there are procedural changes that can be made, create a decision tree to be used from either service system so that there is no doubt about what is done when and by whom. If the two systems involved were under one organizational roof, how would they make sure their clients received the help they need? As new procedures are developed remember that it’s not an us vs them; it’s all of us, working together to improve experiences.

The Belt and Pulley concept being vetted and tested by our design groups

The Belt and Pulley concept being vetted and tested by our design groups

Meeting 4: Confirmation and implementation 

As a final step, the group confirms the final policy and procedural changes that workers can use to better support clients and begins to implement those changes. Are there specific forms that need to be used? Is there shared learning that needs to happen in order for the changes to take place? Create a timeline that is short yet doable to implement the procedural changes and make sure to set at least quarterly meetings to recheck to see how things are working over the next two years.

As time goes on and the new procedures are working, the expectation is that the group will see even better ways to better serve the clients in a collaborative way. Your goal as service providers is to make sure these new tools have “legs” – that the work done together will be immediately actionable and relevant, and can scale or change as supporting systems change.

Introducing the System Metaphor: Belt and Pulley