Individuals and families served by public benefit programs have a deep understanding of systems like Medicaid because they are the ones navigating them. As such, they are critical partners when looking to identify gaps, detect hurdles, and co-create potential system improvements. Journey mapping is a consumer-centered tool that can be used to help state agencies better understand the experiences of the people they serve and create responsive solutions to improve services and systems.

As part of Aligning Early Childhood and Medicaid: Maximizing the Impact of Federal Funding Opportunities (AECM), a national initiative led by the Center for Health Care Strategies (CHCS) with support from the Robert Wood Johnson Foundation, a cross-agency state team in Alaska used a journey mapping process to better understand the experiences of pregnant people impacted by substance use disorders. The state sought to use the information to better align Medicaid and early childhood services to improve maternal health and reduce infant out-of-home placement. CHCS spoke to Daniela Lewy, managing partner at Social Determinants of Health Consulting, and a partner on AECM who is providing technical assistance to Alaska, to discuss journey mapping — what is it, how it works, and how it can help improve system design.  

Q. What is journey mapping?

A. Journey mapping is a tool used to identify and detail a customer’s or user’s experience using a product, service, or system. A journey map of a health care system, for example, can help clinical, administrative, and social service professionals visualize the health care experience from the patient’s point of view to identify touchpoints, pain points, strengths, and opportunities to better align and deliver care across diverse sectors and providers. It helps to not only understand the patients’ clinical journey, but also their motivations and emotional journey.

In typical systems journey mapping activities, everyone — agency staff, providers, and families — is in the same room and hears each group’s perspectives. The group collectively identifies different steps along a patient’s journey, adding their own unique experiences and feelings that happen along the way.  This helps the group understand the obstacles that a patient or a provider might face, before the group jumps to identifying solutions. It’s important to first hear and empathize with those who experience the systems first-hand, and to learn how systems are, or are not, meeting people’s needs.

Q. How can journey mapping illustrate a patient’s or family’s experience navigating health care systems?

A. Journey mapping is a good way to map the personal experiences that make a patient, for example, want to access health care services, decide to go to a provider, and agree to start or continue treatment. It shines a light on the challenges people face, from transportation hurdles to access care, to the emotions involved when making treatment choices. For example, how a provider greets a patient or how well a service is culturally aligned impacts patients’ decisions. In journey mapping, nuances are important, including how a pediatrician giving a hug to a child can make a hesitant mother decide to continue to see that provider and get continuity of care that can improve health outcomes. By asking probing questions that elicit emotions and specificity, those nuances can be teased out and inform solutions that matter to the patient or family.

Q. How does journey mapping identify the touchpoints and challenges of Medicaid members as they interact with health care and other connected systems?

A. Journey mapping focused on policy or systems alignment creates an opportunity to convene state agency staff, service providers, and families who rarely talk to one another, which can help all three groups understand the systems at a deeper level to design more effective policy or systems solutions. By engaging all three groups, you can learn how a system “should” work from the viewpoint of state policymakers, how a system “actually” works from the viewpoint of service providers, and how families “experience” that system from the viewpoint of families themselves. Journey mapping helps spotlight where hand-offs are falling apart, where gaps in services exist, and where systems can better align.

In addition to designing systems solutions, journey mapping sessions provide opportunity for real-time learning and immediate solutions when a provider or agency staff gets to hear directly from a family about what’s working and what isn’t. In one project I worked on, children and teens were explaining to parents, teachers, and police officers their fears of getting to school when they had to walk in a less safe part of their neighborhood. There was one street corner that caused them a lot of anxiety. But there was no need to wait for a whole system redesign when additional supports could be added right away by having more adults at that street corner before and after school. Thus, when doing this process in real time, some things can get fixed right away while the group explores bigger system solutions, which may take more time.

Q. What is something that has surprised you in a journey mapping activity?

A. That’s the fun part — these types of activities always lead to something that is surprising! For the AECM project with the Alaska team, due to the very rural nature of the state and the remote communities we were focused on, we decided to do the journey mapping activities virtually and in tiers. It was surprising how well the virtual journey mapping session worked and how it enabled some individuals who are more introverted to share their thoughts by typing comments in the Jamboard, and even off camera if they wished. For the journey mapping activities with the families, being able to engage them through anonymous phone calls was a good strategy for birthing parents who used drugs during their pregnancies since there is so much stigma around that.

Q. What are some limitations with journey mapping?

A. It’s important to pay attention to how the recruitment is done and who is participating — sometimes we don’t get all of the right voices at the table, especially when an issue has a lot of stigma associated with it. Also, in journey mapping and other activities that engage end users, it’s important to not just include one token person to represent the experiences of the many. You also have to pay attention to who is doing the facilitating, the listening, and the coding or synthesis of the information shared, since biases can creep in.

Q. What happens after journey mapping?

A. One of the products of journey mapping should be a list outlining the obstacles families face when navigating a particular system. It’s important for families to decide which pain points are the most important ones to focus on — they know what matters to them most. Low hanging fruit shouldn’t be picked just because they are easy to deal with, since they might not yield big improvements for families. After the first step of journey mapping, additional sessions are needed as part of an iterative redesign process for the group to collectively identify areas of opportunity for improvements and to co-create solutions that can lead to more effective policies or programs, or better aligned systems.

Q. Can you share an example of policy or program changes that were implemented after journey mapping?

A. I worked with partners focused on improving a school discipline policy that impacted students who were charged with a crime when they were out of school. The policy resulted in students being suspended from school and participating in a home-school program until the issue was resolved via the legal system. What the education sector didn’t realize was that the legal process sometimes took six months to a year to get resolved — with 80 percent of those cases resulting in not guilty decisions — but during that time, the child was out of school, often unsupervised, not always receiving the home-based education program, and more likely to commit additional crimes. Once students, state, and local education and juvenile justice system leaders were able to journey map the students’ experiences, the challenges and misalignment between the education and juvenile systems were clear. The cross-sector agencies and other stakeholders co-created a new in-person education program that included supervision and enrichments, which led to better outcomes.

Q. What advice would you give to someone interested in journey mapping?

A. It’s important to remember that journey mapping is just the first step of a larger redesign process and that end users — such as Medicaid members — have to be part of the solution-making process. Policies should not be made without listening to those most impacted by systems and without understanding the human side. System alignment work is often focused on all of the systems pieces that make the whole, but that process needs to be more human centered.

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