Small Nonprofits and the Need for Sudden Capacity Building

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July 17, 2016, Valley News

“Two or three years from now, it’s going to look different than it does today,” said Hilde Ojibway, the new interim executive director of Headrest Inc. in Lebanon, New Hampshire. “I don’t know how. But it will.”

Headrest, a small, front-line substance abuse agency, was recently required to change from grant funding to fee-for-service in the midst of a vast increase in demand caused by the opioid epidemic. Periods of external change like these can create an organizational spiral, as we have seen before, and such spirals can manifest in odd ways. For instance, despite a waiting list for the transition program and  notwithstanding the loss of per diem revenue the vacant beds represent, six of Headrest’s 10 beds are empty for want of trained staff.

Headrest’s previous executive director was both the administrative and clinical head of the agency even as administrative requirements were likely skyrocketing and everything in its operating environment was hitting a fever pitch. Most of Headrest’s approximately $700K annual budget comes from state and local funding, and that now includes a new load of onerous paperwork. The organization will also face larger external positioning issues that will require a strong collective strategic mindset.

Changes at Headrest are in the works even as New Hampshire is moving forward with a five-year plan that will spend up to $150 million in federal Medicaid funds to expand the state’s capacity to treat substance use disorders and mental illness and to integrate that care into the broader health care system. In the Upper Valley and southwestern New Hampshire, Dartmouth-Hitchcock and two of its hospitals have applied to serve as administrators of a so-called integrated delivery network that would include six hospitals, six behavioral health groups, three peer recovery organizations, three county governments and three regional public health councils.

The opiate crisis continues to mount. “Overdoses from heroin, prescription drugs, and opioid painkillers have overtaken car accidents to become the leading cause of injury-related deaths in America,” The Economist reports. As described in greater detail in this HHS fact sheet, “In 2014, they were responsible for 28,647 deaths. Between 2001 and 2014, deaths from heroin overdoses alone increased six-fold, according to the National Institute on Drug Abuse. On average, 125 people a day die from drug overdoses, 78 of them from heroin or painkillers. These numbers have been compared to deaths from HIV in the late 1980s and 1990s.”

The long and short of the situation is that New Hampshire has a bill it cannot afford to pay and little Headrest is left to figure out how to manage the crushing debt of it. Now it’s Ojibway’s turn to take on Headrest’s next stage, with an eye to the stage that follows that, and that may require a new approach. With an interim director, the agency will have time to figure it out, but the board better be ready to get down to work because the many decisions to be made in the next year will chart the organization’s future.—James Schaffer and Ruth McCambridge