Innovator Interview: Commissioner Maggie Hart Stebbins and Behavioral Health Director Katrina Hotrum, Bernalillo County, New Mexico

Maggie Hart Stebbins has served on the Bernalillo County Commission since May 2009. During her tenure, she has focused heavily on improving access to mental health and substance use treatment services and supporting at-risk children and their families.

Katrina Hotrum is the director of Bernalillo County’s Behavioral Health Department, where she leads the County’s behavioral health initiative aiming to address the current mental health, substance use, addiction, and homelessness crisis.

This interview has been edited for clarity and brevity.

What was the challenge facing Bernalillo County at the project’s outset?

Hart Stebbins: Bernalillo County has been very progressive on behavioral health because of a recognition that so many people who end up in our jails are there because they have untreated mental illness or they can’t get appropriate services out in the community. For quite a while, our focus was on recognizing the role of substance use and mental illness in the community. We have always had historically high rates of heroin use – consistently above national rates in use per-capita and overdose per-capita. So all of these factors were kind of whirring around and then a couple years ago there were very highly publicized tragic interactions between law enforcement and people who were mentally ill. There were many shootings, several deaths, and a high proportion of those who died were mentally ill. So we had this confluence of factors. We asked on the 2014 general election ballot if the people wanted a behavioral health tax, and 69% said yes. So there was pretty broad awareness in the community that this was problem that needed to be addressed. Once we passed the tax we had to make some decisions about how to employ it. And it was great coincidence that that’s when the GPL was on site to help us with that process.

Hotrum: Specifically, the challenges we are facing are how to stabilize individuals in crisis, get them to services they need, and then step them up or down in to services as they need it. For example, individuals experiencing a mental health crisis currently go to the emergency room and then leave (if there’s not an in-patient stay), and there’s typically nothing for them to leave to. Services are set up three days out, and that’s only if you can see a psychiatrist to get services in place. The expectation for the tax from the community is that we would build wrap-around services plus a crisis stabilization center.

How do you get from there to releasing the first request for proposals (RFP)?

Hotrum: The investment in reduction of adverse childhood experiences (ACEs) was one of the recommendations coming from our community partner in Arizona, but it was only for birth to five. Based on the analysis from the GPL we decided we should be looking at a broader range – really birth to 18. Because we have higher rates of ACEs in this community. Then there was a tragic event that happened. A10 year old girl was sexually assaulted by her mother’s boyfriend, then shot up with drugs, dismembered, and murdered. The community was outraged and wanted to know what we could do. The commissioners wanted to act quickly and show how the behavioral health tax could impact future lives. That investment for ACEs was increased from $1m to $3m, and that’s when the GPL really started working with us on problem-based procurement. The GPL fellow took us through training, helped us write the first RFP, and took us through the contract management piece.

How was this RFP process different?

Hotrum: The GPL fellow was able to take a look at our current contracts and figure out what we could do to make them better. Instead of saying prescriptive things like “you will have a 1:15 staffing ratio,” which could or could not be meaningful, it was “how are you going to support the client and what types of outcomes are you going to achieve?” The GPL ended up teaching us these strategies for problem-based procurement. That excited the current providers because it engaged them from the very beginning on helping us to actually solve the problem instead of being so prescriptive on how we want them to solve the problem. So we have gotten a lot of support from the community. It has allowed providers to be creative in how they’re helping us to resolve these issues.

Hart Stebbins: I come from the policy-maker end, and it gave us an opportunity to really focus on outcomes. I think the public is really starting to ask for that – what are we getting for our dollar. So having the GPL fellows on site for this new strategy for procurement allowed the whole process to be more outcomes focused as opposed to just putting numbers out there and maybe not having a good evaluation structure in place where we could really tell whether programs were having the desired impact.

How have County staff responded to these new approaches?

Hotrum: We [the Behavioral Health Department] responded really well. Procurement is one of the ones that take a little bit to come around. It’s a different process for them, but they’re coming around too. We were actually really excited about it and we also partnered with the University of New Mexico’s Institute for Social Research. They are collecting data and were trained by GPL on outcomes and performance. The projects we have are pilot projects and expansion is really going to be based on outcomes, whether we are serving the population we intended to serve, if programs are meeting the marks, and what are we learning about that. One of the other things we’ve also learned early on is that not every program that we are trying to fund in this way may succeed. But we will learn a lot about this and we may have different outcomes that might actually be better for our community then the ones that we thought we’d have. So that stuff is very exciting for us.

Hart Stebbins: Government procurement is just fraught with risk. So our staff is just constantly on edge about violating any procurement laws. So they have been very conservative about this process. But particularly thanks to the GPL fellow having direct one-on-one conversations with procurement staff they’ve begun to feel more comfortable with the process and make a real effort to incorporate it in to their work. We just recently got the authority to become a home-rule County, which allows us to write our own procurement rules. So we have a committee working on it that has spent some time with the GPL fellow to make sure whatever we do in this new procurement code accommodates the new problem-based procurement strategy.

What impact has this had outside of the Behavioral Health Department?

Hotrum: The Addiction Treatment Department is also embracing this. We are going to provide an education session to help them transition to more performance-based contracting and more problem-solving RFPs. So we know there is at least one other department that is embracing this concept. We’re looking at ways of applying this more broadly across the County right now.

Hart Stebbins: Once this is clearly spelled out in the new procurement code, there may be other departments who will take a look at it and apply it to their own needs. It might be a little bit too early to say that it’s been adopted County-wide.

What are your next steps with the Behavioral Health initiative?

Hotrum: We have already issued other problem-based RFPs and we’re getting ready to launch additional ones. When the first GPL fellow got on board she had to do a lot of pioneering for us. She had to get the City and County speaking the same language, and get definitions aligned for service delivery so we weren’t duplicating efforts. So she really set the stage to allow the implementation of problem based procurement and performance contracting. We now plan on doing that with all of our RFPs. Some of them will need more structure, such as the mobile crisis teams, because there are certain things that they have to do. But the GPL fellow was instrumental in showing us the areas where we could be creative and where we could allow the applicant to use their niche and nuance in resolving issues in our community. That’s the stuff that we’re carrying forward. We’re setting up the implementation pieces that GPL started for us.

What has been the community’s response to all the work thus far?

Hotrum: The community has been engaged in every step of the way. It is important for us to implement programs that would be meaningful for the community that is struggling with this as a whole. The community was very clear that this was not our money – that this was their money – and our job was to steer the ship and implement programs that would be successful and impact the community in a positive way. So with that, we set up subcommittees that are made up of the community – people with lived experience and subject matter experts – in four categories (prevention/intervention/harm-reduction, supportive housing, crisis service, and community support). So the community is involved in how we spend those dollars and shaping the program that will lead to our success.

Hart Stebbins: We’ve recently had some coverage from the local newspaper that said we weren’t moving fast enough, but I think a lot of the people that have been engaged are pushing back on that. All of us wish the services were on the ground and having an impact right away, but the people who are the most intimately involved understand the value of this new strategy and are willing to defend it publicly. And that’s really good to see.

What has your experience been working with the GPL?

Hotrum: They’ve been great. They came in and they really challenged us on our way of thinking, and challenged us that we could do things differently. And that was a struggle for me and my department at first, but then really trying to understand how data could drive performance and outcomes actually became really reassuring for the behavioral health dollars. We could actually show and demonstrate to the public our successes. And we’re willing to reinvest in programs that work to positively impact this community. So it’s been great and refreshing to work with them.

Hart Stebbins: I would agree 100%. I think one thing that I really valued working with both GPL fellows is their insistence on us doing it as well as we possibly could. Their commitment to excellence and bringing us to a higher standard – cause we’re a small local government of course there will be pushback against trying to do things that are new or different. But they both were able to take the time to help us understand why this would serve our community better than the way we had been doing it before.

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