My time at McGeorge School of Law’s Elder and Health Law Clinic was a defining experience in my legal education and career. It allowed me to build on my foundation of service from my time in the Marine Corps while deepening my dedication to serving vulnerable populations with compassion and diligence.

In the Marine Corps, I served on the military honor guard, providing funeral honors for fallen marines. Working alongside retired marines gave me insight into the challenges aging individuals face. I had always viewed the marines of the past as strong and invincible, but I came to see how aging made them vulnerable. This experience instilled in me a commitment to advocate for the elderly — a commitment I carried into my work at the Elder and Health Law Clinic.

During my second year of law school, I took on a leadership role at the clinic, representing clients under the supervision of a licensed attorney in Elder Abuse Restraining Orders and complex elder abuse litigation. One significant case involved an elderly couple who transferred the title of their home to family members, believing they retained a life estate. They were later served with an unlawful detainer and a restraining order that barred one client from returning home. I filed a civil complaint alleging fraud and answered the unlawful detainer action. I also filed a motion to consolidate the cases, which was hotly contested. Successfully arguing the motion, while negotiating a stay on the restraining order, was a pivotal moment in my development as a legal advocate. It taught me the importance of preparation, thorough research, and strategic thinking.

In addition to managing my caseload, I mentored newer students in the clinic, helping them navigate complex cases and build their legal skills. This mentorship role deepened my understanding of teamwork and leadership and reinforced the value of collaboration in legal practice.

The skills I developed at the Elder and Health Law Clinic — working with vulnerable clients, thorough case preparation, and courtroom advocacy — have had a lasting impact on my work today as a Deputy District Attorney for the Los Angeles District Attorney’s Office. I now prosecute serious and violent felonies, often working with crime victims who are under immense stress. My time at the clinic taught me how to establish trust, listen actively, and communicate legal concepts clearly — skills that are essential in working with victims and their families. The clinic’s emphasis on detailed case preparation also laid the foundation for my ability to handle high-stakes felony cases with confidence and care.

The Elder and Health Law Clinic gave me critical legal tools while reinforcing the importance of empathy and advocacy. It also allowed me to make a meaningful impact on the lives of vulnerable individuals, something that remains central to my career today. For any student seeking a transformative experience, I wholeheartedly recommend it. It’s an opportunity to hone your legal skills while deepening your understanding of the law’s potential to uplift those in need.

By McGeorge School of Law alumnus Daniel M. Ilacqua, ’19.

“PDSAs are a tool from the Transformational Change Partnership that we have integrated into our work and decision-making at our agency. We often ask our clients to help develop PDSAs so we can incorporate their change ideas into our system.”

– Placer County Behavioral Health Professional and TCP Participant

The value of continuous quality improvement

Transformational change in public systems doesn’t happen overnight. It requires thoughtful experimentation, learning, and adaptation. One powerful tool for this process is Plan-Do-Study-Act (PDSA)—a structured, iterative approach that allows organizations to test small-scale changes before committing significant resources to full-scale implementation.

The Transformational Change Partnership (TCP) has seen firsthand how PDSA cycles empower counties to make data-informed decisions, reduce risks, and create sustainable improvements in behavioral health, education, and other public systems. By focusing on continuous learning, PDSA prevents costly missteps, preserves goodwill, and leads to more effective solutions.

What is PDSA?

PDSA is a structured, low-cost, rapid cycle approach that guides organizations through testing and refining changes to learn what works best before full implementation:

  • Plan: Define the objective, make predictions, and outline the steps for testing a change, including data collection methods.
  • Do: Carry out the test on a rapid small scale, document observations, and begin analyzing data.
  • Study: Analyze results, compare findings to predictions, and summarize lessons learned.
  • Act: Refine the change based on insights gained, determine modifications, and plan the next test.

Why PDSA Matters for System Transformation

When counties and public agencies adopt PDSA, they gain three critical benefits:

  1. Saves Resources: Instead of investing time and money into an untested implementation that may not work well, PDSA allows teams to test small changes first and learn what works best. This ensures that only effective strategies are scaled up, maximizing impact while minimizing waste.
  2. Preserves Goodwill: Too often, well-intentioned initiatives fall short, leaving stakeholders frustrated and disengaged. PDSA helps build confidence by ensuring that changes are refined and validated before full-scale implementation.
  3. Drives Better Outcomes: Learning through PDSA leads to stronger solutions than simply launching an initiative and making adjustments later. By iterating and improving at every step, organizations create programs that are not only functional but truly responsive to community needs.

Real-World Examples of PDSA in Action

Across multiple counties participating in the Transformational Change Partnership, PDSA has helped agencies navigate complex challenges and improve services. Here are a few examples of how public-serving organizations have leveraged this approach:

  • Enhancing Mental Health Transitions for Justice-Involved Individuals: Placer County is applying PDSA to improve communication between in-custody providers and community-based mental health services. By testing how mental health clients booked in jail can be successfully connected to an appointment within 14 days of release, the county is identifying and addressing gaps in coordination and information sharing before expanding the approach.
  • Expanding Youth Engagement in Service Design: Monterey County is using PDSA to test how to better involve students in shaping behavioral health services. By piloting empathy interviews, they aim to refine the questions and interview format to ensure youth voices are meaningfully included in decisions about service offerings and providers.
  • Improving School-Based Behavioral Health Guidance: Santa Cruz County is using PDSA to test how best to disseminate and support the use of state materials on privacy regulations (HIPAA/FERPA) for school-based counselors. By piloting these materials with a small group of counselors and families, they aim to refine the content and its distribution strategy before a broader rollout.

Centering Equity in PDSA

In order to maximize the quality and effectiveness of a change, it is helpful to investigate who is at the table when designing and implementing PDSAs. Each phase of the PDSA cycle can integrate an equity lens by asking:

  • Where did the change ideas being tested come from? Were impacted communities involved in generating potential solutions?
  • Who was involved in planning and testing? Are diverse voices, including those most affected by the issue, engaged?
  • Who is analyzing the results? Are stakeholders contributing to the interpretation of findings?
  • How are disparities being addressed by the change? Are changes leading to improved equity in outcomes, or do they reinforce existing inequities?

Making PDSA a Standard Practice

Embedding PDSA into everyday operations shifts an organization’s culture from reactive to proactive. It creates a mindset of continuous improvement, where learning is valued, and innovation is encouraged. For counties engaged in transformational change, this approach ensures that new strategies are not just well-intentioned but proven to work before being widely adopted.

The Transformational Change Partnership supports counties in integrating PDSA into their system improvement efforts, helping public agencies move beyond guesswork to data-driven, community-informed solutions. As more organizations embrace this tool, they position themselves to create meaningful, lasting change—one cycle at a time.

Final Thoughts

Transformation is not about making one big change; it’s about making small, strategic changes that add up to something bigger. PDSA provides a roadmap for testing, refining, and implementing solutions that truly serve communities. By embracing this approach, public agencies can avoid costly missteps, sustain trust, and build systems that are both effective and equitable.

Interested in learning more about how PDSA can support your system improvement efforts? The Transformational Change Partnership is here to help.

Diksha Jagga is a third-year student at McGeorge School of Law. 

Participating in the Elder and Health Law Clinic was a defining experience in my legal education. I joined the clinic to gain practical experience in estate planning and elder law, building on my background in financial planning and wealth management. While I expected to work on trusts, developing estate plans, modifying existing trusts, and addressing issues related to guardianships and healthcare directives, I didn’t anticipate how much I would learn about the personal and emotional side of legal practice.

Many of the clients I worked with were facing difficult situations, from concerns about diminished capacity to family disputes over trusts. Others needed guidance on how taxes would affect their estate plans. In those moments, tax concepts became less about numbers and more about what they meant for a client’s family and future. Explaining these issues in a clear and supportive way made conversations that could feel overwhelming much more manageable.

The experience I gained expanded my understanding of how the law intersects with family dynamics. While my financial background gave me a solid foundation, applying it in real-world scenarios showed me how careful planning can provide reassurance and stability.

I’m especially grateful for the mentorship of Professor Melissa Brown, Staff Attorney Lacey Mickleburgh, and Professor John Cary Sims. Their guidance challenged me to think critically, refine my legal analysis, and build confidence in my ability to serve clients. They showed me how to approach legal problems with both technical skills and genuine care for the people involved.

This experience solidified my commitment to estate planning and elder law. Behind every legal issue is a person, often facing a major life transition. Carrying that understanding forward, I’m dedicated to practicing law in a way that blends expertise with empathy — ensuring clients feel supported as they make decisions that shape their futures.

By Diksha Jagga, a third-year student at McGeorge School of Law. 

Malina Walker, ’22.

I have a JD because I graduated from law school. I’m licensed to practice law because I passed the California Bar Exam. But, I’m an attorney doing some good in the world because of the McGeorge School of Law Elder and Health Law Clinic.

Going to law school and passing the Bar Exam are important (critical!) things to do if you want to be a lawyer, but practicing law in the real world requires doing just that. It requires handling tangible files, looking at real evidence, reading statutes that apply to actual facts, navigating physical courts and clerks, and working with living human beings.

When I started working for Senior Legal Services of El Dorado County as a brand-new attorney, I knew how to do the actual work of lawyering from day one: how to manage a client file and meeting, keep good records, and ask good questions. I knew how to navigate client questions, deceptions, fears and furies. I knew how to take quiet moments to listen with compassion and how to re-direct to the matters at hand. I knew how to clarify and manage expectations and how to honestly address disappointments. I learned all of this because I worked with real clients and had continuous, expert, and supportive mentorship in the clinic. 

None of this means I didn’t have a lot to learn when I started working — I did, and still do. But, I had a strong base to start my career because I worked at the clinic. It is critical, I think, to appreciate this — the clinic is a law firm. It is staffed by licensed attorneys and student attorneys who don’t just offer “tips and tricks” or direct clients to other resources — they are the resources, and they do the work. 

A final note for those interested in the Elder and Health Law Clinic: If you’re uncertain whether this is the right area for you, but are curious about the valuable experiences it offers, then I would argue do it anyway. Because even if you don’t practice Elder Law, the kinds of nuanced and sophisticated legal and human skills you’ll develop will serve you wherever you practice in the future. Knowing how to assess capacity, having the skill to navigate sensitive human issues like independence, or dignity, and practicing with the awareness that your clients are people with context will make you a better lawyer. The “context” in Elder Law might involve issues like early dementia, loss of independence, or hearing impairments. However, if you’re trained to recognize these types of human challenges, you’ll become more attuned to the unique “context” of any client. This could include concerns such as a desire for revenge, fear of homelessness, lingering distrust of lawyers due to a past divorce, or any other personal matters they bring with them, beyond the legal issue they want you to address. And sometimes, they don’t even have a legal problem, but you can help them anyway — yet another skill you can learn in the clinic.

By McGeorge School of Law alumnus Malina Walker, ’22.

Lauren Sorokolit, ’13.

The Elder and Health Law Clinic at the University of the Pacific McGeorge School of Law introduced me to topics and issues that shaped my current legal career in the healthcare field. As a student in the Clinic, I was given the tools to find out what it would feel like to work with different subjects and in different forums, which helped me map out my future path.

As a first-year law student, I learned that the McGeorge Legal Clinics were the best way to gain insight into life as an attorney, as well as to help people in the Sacramento community. I was drawn to the Elder and Health Law Clinic because of the diverse issues those clients faced. I learned that students working in the Elder and Health Law Clinic could expect to encounter clients wishing to execute wills and trusts and powers of attorney; clients having difficulty navigating public benefits; interpersonal disputes; and housing crises.

Through the Clinic, I was exposed to different forums for addressing issues, which helped me to build confidence in myself as an emerging attorney. There was no “one-size-fits-all” answer in the Clinic. I enjoyed getting to know my clients and helping them with issues that were often different from the issues that had brought them in the door. Professor Melissa Brown encouraged us to investigate and independently craft unique solutions for our clients.

One of my clients was denied a prescription drug benefit through the Medicare program. Prior to law school, I had no experience with public healthcare benefits, but I gained a foundational knowledge through the Elder and Health Law class, and learned even more in the Elder and Health Law Clinic. I ultimately filed an appeal with the Center for Medicare and Medicaid Services (CMS) on behalf of my client. I submitted briefing on the issue to CMS and argued my case before a federal administrative law judge. My client was ultimately able to obtain his needed prescription medication.

Additionally, I drafted multiple wills, trusts, and powers of attorney. When we had a client approach us for help with an abusive family member, I appeared before a Family Court judge to obtain a temporary restraining order. When I didn’t have the tools to help my clients, I worked with other community organizations to help them find appropriate help.

I found myself drawn to healthcare issues while working in the clinic. I was able to connect with multiple alumni in the healthcare field through McGeorge’s Career Services Office in order to gain a better understanding of the different types of healthcare attorneys. I also signed up for relevant internships (e.g. the Center for Medicare Advocacy) and externships (e.g. Office of the Attorney General, Bureau of Medi-Cal Fraud and Elder Abuse) and took classes such as Health Care Law, Administrative Law, and Health Care Policy.

Ultimately, I found myself drawn to in-house healthcare practice. I liked the idea of collaborative problem-solving within an organization of people dedicated to helping others. I am now in-house counsel with a children’s health care system in Fort Worth, Texas. The healthcare field can be complex and difficult to navigate. I am thankful for my experience in the McGeorge Elder and Health Law Clinic, which set me up for success in my field.

By Lauren Sorokolit, ’13.

Crystal Viruet Witherell, ’19.

Like many students, I went to law school to use my education to make a meaningful impact in the world. As a first-generation student, I did not fully grasp all I would need to learn to be an effective advocate one day. The Elder and Health Law Clinic at the University of the Pacific McGeorge School of Law was a key part of that journey. I gained practical experience, and I saw positive results through the clinic even before graduating. That kept me motivated to keep going because my experiences in the clinic often reminded me of why I chose to pursue law in the first place and equipped me with the foundation I needed for the future.

Working directly with elderly clients, often on protective restraining order cases and estate planning, was eye-opening. Learning from professors, like Melissa C. Brown, and other supervising attorneys was invaluable. Professor Brown emphasized serving the whole client. That meant meeting people where they were and guiding them through their transitions with empathy and clarity. I saw firsthand how much of a difference digestible legal information and having a reliable advocate could make. Making people feel heard and respected empowered them along their journey. The assistance provided in the clinic translated to a real impact in people’s daily quality of life. I knew I wanted to continue doing that in my work for years to come.

The clinic also helped me practice time management. It gave me experience with legal software which became an advantage in the real world. I learned how to communicate effectively with distressed clients and about Probate Court procedures, both of which have been applicable daily in my current and past roles. As a new attorney, the skills I gained in the clinic helped me hit the ground running, ready to learn and grow. I took what I learned about the law, communication, and the importance of preparation with me during my years in private practice and my transition back to public interest work.

Now, as a guardianship attorney, I continue to help clients through significant life transitions. Thanks to the foundational training in the clinic, approaching each case with compassion and confidence is natural for me. The clinic didn’t just prepare me for work — it helped me grow as a person, lawyer and better understand how to help people. I will continue to carry those skills for the rest of my career. I’m incredibly grateful for that experience. I can’t recommend legal clinics enough if you’re a law student.

By Crystal Viruet Witherell, ’19. Crystal is a guardianship attorney in the Child Abuse Prevention Program at Legal Aid of Sonoma County.

Natalia Osorio-Elizondo, ’24

When I started law school, I knew I wanted to use the opportunity to explore ways to advance my passion for serving marginalized communities with my law degree. While I had experience in nonprofit immigration work, I was eager to branch out and explore new areas of law. My commitment to advocacy and social justice ultimately led me to the Prisoner Civil Rights Mediation Clinic in my final year of law school.

Before joining the clinic, I had no prior experience working with incarcerated individuals or engaging in mediation. It was exciting to learn about the mediation process and its objectives. Serving as a neutral co-mediator was a significant shift in perspective for me, as my previous legal work had always been on one side of a claim.

Professor Ederlina Co encouraged us to critically examine the systemic forces that shape the mediation process and the experiences of incarcerated individuals. Early in the semester, reading The New Jim Crow by Michelle Alexander provided crucial context for understanding the challenges that incarcerated litigants face when bringing their claims. Additionally, visiting Folsom State Prison solidified my understanding of the conditions in which these litigants live and the barriers they navigate.

The clinic offered a unique and rewarding experience that deepened my understanding of civil rights litigation and mediation. Beyond gaining substantive knowledge, I developed valuable legal skills, including working with incarcerated clients and maintaining neutrality and impartiality.

Working with the plaintiffs reaffirmed my commitment to serving marginalized communities in client-centered work. Every litigant I worked with expressed gratitude that we were there to hear their stories, and I felt honored that they trusted us enough to share them. Although we did not represent them, it was essential to me that we accurately conveyed their narratives and interests to the judges through our bench memos. Even as neutral co-mediators, I believe that meeting with the prisoners, either by phone or in person, before their mediations, helped to mitigate the inherent power imbalance in these cases and the broader system.

Furthermore, adopting a neutral stance throughout the mediation process and collaborating with judges allowed me to see the bigger picture and assess critical information effectively. Learning to remain neutral was a valuable lesson in my legal career, as my prior experiences had always positioned me as an advocate for one side. The judges we worked with provided invaluable insights into neutral mediation, helping me refine my ability to analyze cases objectively. Even if I only represent one side in my future career, I now have a greater capacity to assess a case’s strengths and weaknesses from an unbiased perspective.

Overall, my experience in the Prisoner Civil Rights Mediation Clinic has made me a better lawyer. Engaging with plaintiffs in this setting was an invaluable opportunity for any law student, and I am grateful for the skills and insights I gained. This experience has reinforced my dedication to using my legal education to support and advocate for marginalized communities.

By Natalia Osorio-Elizondo, ’24.  

Bernadette Bet-Mashal, ’21

During law school, I had the privilege of participating in the Elder and Health Law Clinic, an experience that shaped not only my legal skills but also my confidence in practicing law. Like many law students, I went in eager to learn, but I left with something a textbook could never teach — firsthand experience that prepared me to open my own practice not long after passing the California Bar Exam.

What stood out the most about the clinic was how much real-world experience I gained, even beyond what I was getting at a law firm as an intern. I wasn’t just researching legal theories or drafting memos — I was in the trenches, working directly with clients, drafting discovery requests and responses, preparing trial binders, and engaging in meet and confer meetings with opposing counsel. I even gained valuable trial experience, something many law students don’t get until much later in their careers.

Although the clinic primarily focused on elder and health law, my supervising attorney worked closely with me to incorporate cases related to breach of contract matters and transactional work, aligning with my growing interest in contract and business law. By the end of my time in the clinic, I had practical experience that set me apart from many new attorneys. More importantly, I had confidence — the kind that only comes from doing the work, not just reading about it.

One of the biggest takeaways from the clinic was how much I valued the attorney-client relationship. Working directly with clients gave me a deep appreciation for the responsibility we have as lawyers. I saw how much they relied on me, and it made me determined to never be the kind of attorney who gives the profession a bad name. That experience instilled in me a work ethic and a commitment to fairness that still drives my practice today.

Looking back, I can say with certainty that the legal clinic is the reason I had the confidence and experience to open my own firm here in Sacramento. My primary focus now is ensuring that my clients — whether they’re business owners, individuals in contract disputes, or those facing legal uncertainty — are treated fairly and receive the justice they deserve. The skills I gained in the clinic continue to shape the way I advocate for my clients today.

For any law student considering clinic work, I can’t recommend it enough. It’s one of the best ways to bridge the gap between theory and practice, and for me, it was the foundation that made my legal career possible.

By McGeorge School of Law alumnus Bernadette Bet-Mashal, ’21.

Kennedy Skinner is a second-year student at McGeorge School of Law. 

I had the privilege of working at the Elder and Health Law Clinic at the University of the Pacific McGeorge School of Law in the summer and fall of 2024.

I learned the importance of an estate plan and how it can give security to the individuals and their families who walk through the clinic doors. Estate planning is not one-size-fits-all — where every plan illustrates the client’s family dynamics, wants, desires, and entire lives all wrapped in legal documents. Understanding how crucial these documents are for ensuring the client’s wishes are respected while balancing the sensitive and emotional nature of the process was an excellent learning experience to build my professional and personal skills.

The majority of my experience at the clinic involved drafting and reviewing various documents and personal assets of our clients. Initially, the process was overwhelming to try and deliver what the client wanted while learning the intricacies and details to consider while drafting these documents. However, with the help of my supervising attorneys Lacey Mickleburgh, John Cary Sims, and Melissa Brown, I became more comfortable and confident with identifying the important provisions and understanding the reasoning behind them. Learning from the supervising attorneys helped me grow my technical legal skills and gave me invaluable insights into the ethical and emotional aspects of practicing law. They additionally taught me how to properly balance myself with my work after experiencing a tough recovery from an injury.

During my time in the Elder and Health Law Clinic, I additionally took the course Elder Law and Social Policy with Professor Brown. The course dove deeper into the elder law field and encompassed many other issues, such as Medicaid planning, long-term care planning, and issues faced by our aging population. Working in the clinic gave me a broader understanding of how all the topics in the course intersect with estate planning and the larger picture of elder law.

The experience at the Elder and Health Law Clinic wasn’t just about my professional development — it was a personally enriching experience. Working as a team with the supervising attorneys to create a difference in the clients’ lives was incredibly rewarding. Helping the clients develop plans that would ease their burdens, give security to their families, and ensure their wishes were carried out gave me a deep sense of fulfillment. With the encouragement of the clinic, I received a scholarship to the California Advocates for Nursing Home Reform (CANHR) Elder Law Conference, which I attended in fall 2024 and learned from attorneys across the state about developments in the elder law field.

The lessons I learned at McGeorge School of Law’s Elder and Health Law Clinic illustrate the significance of estate planning. Elder law has solidified my personal and professional path in estate planning. I cannot wait to bring security to my future clients.

By Kennedy Skinner, a second-year student at McGeorge School of Law. 

“Part of the overall framework of doing ‘the work’ is really honoring co-production and moving from tokenized youth voice into more of a true co-creation process.”

– Santa Cruz County Behavioral Health Professional and TCP Participant

Introduction

The intention of this blog is to share learning and insights from the Transformational Change Partnership, which develops the capacity of public-serving agencies to advance system-level changes that improve outcomes and reduce disparities. Backed by interdisciplinary research, the blog is based on learnings from the TCP and presents practical actions that practitioners and policymakers can use to diagnose, reimagine and improve public systems. 

As we increasingly recognize the complexity of diversity — not only in ethnicity but also in the entirety of identities that shape our communities and their needs — there is a growing urgency to create truly inclusive approaches.  This vision lies at the heart of “co-production,” a transformative approach redefining the creation, implementation, and evaluation of services and policies. More than just consultation, co-production invites community members to the table as equal stakeholders, leveraging their lived experiences to drive meaningful change.1,2 While healthcare often takes center stage in these conversations, the principles of co-production extend far beyond, influencing sectors such as education, research, housing regeneration, and public policy.3 4 5

Co-production is not an abstract ideal; it is becoming a cornerstone of modern governance and public service. Across the United States, federal and state agencies are embedding co-production into their frameworks, recognizing that true progress occurs when community members are active partners rather than passive recipients. The Transformational Change Partnership (TCP) provides an actionable model for achieving this shift, supporting counties as they build sustainable and inclusive systems of care.

One powerful example is California’s Sacramento County Children’s Coalition exemplifies this shift. Appointed by the Board of Supervisors, this advisory body evaluates community needs, assesses services, and provides policy recommendations to promote the health and well-being of children, youth, and families.6  Around the Coalition’s table sit voices from every corner of the community: a retired nurse who cared for generations of children, a former pediatrician with deep knowledge of health equity, a retired educator who understands academic barriers, a youth advocate passionate about behavioral health, and more. Together, they form a tapestry of lived experiences, ensuring county decisions regarding youth and families are shaped by diverse community perspectives. One large project that emerged from the Coalition was the creation of the 2022 Children’s Report Card, a 122-page comprehensive review of the challenges that Sacramento County youth and families face to inform policymakers, the majority of which was written by community members. Co-production in action provides a direct pathway to reduce disparities that have excluded far too many individuals from accessing services originally designed to serve them. 

At its core, co-production goes beyond improvement of services — it’s about creating trust, fostering mutual respect, and ensuring that systems are not only sustainable but responsive to real community needs.7 8 9 When community members are treated as equal partners, the results are transformative: policies become more effective, services more equitable, and outcomes more lasting.10 This is a fundamental shift in how we approach collaboration and progress. TCP enables and amplifies such efforts by providing county agencies with the training, frameworks, and partnerships necessary to implement systemic change in collaboration with the very communities they serve.

Key Learning: “When community members are treated as equal partners, the results are transformative: policies become more effective, services more equitable, and outcomes more lasting.” 

Co-Production: The Peak of the Ladder of Co-Production 

The Ladder of Co-Production, conceptualized by Sherry Arnstein and later modified by the National Co-Production Advisory Group, illustrates the progression of citizen involvement in decision-making processes (Figure 1).11 At its apex lies co-production, representing the highest form of partnership where power and responsibility are equitably shared between professionals and community members.12 13 True co-production integrates lived experiences, perspectives, and realities of marginalized groups — voices often overlooked by decision-makers shaping programs, services, and strategies. This approach is not simply about inclusion; it’s about equitable partnership, ensuring those most affected by the inequities and those with the closest touch points to community realities are actively involved and trusted leaders.  

In contrast, the lower rungs — such as informing and consultation — often involve superficial one-way communication or tokenistic involvement, lacking genuine influence over outcomes.14 By striving for co-production, organizations can ensure that services are not only designed for the community but led by the community. TCP helps organizations move beyond surface-level engagement toward deep, structural inclusion, successfully seen in Placer and Yolo Counties.

Figure 1. Ladder of Co-Production.

Figure 1. Source: Ladder of co-production – TLAP. January 13, 2021. Accessed January 2, 2025. https://thinklocalactpersonal.org.uk/resources/ladder-of-co-production/.

Why it Matters – From the Perspective of a Co-Production Consultant 

“I came to understand a critical factor contributing to these barriers: the lack of representation among those designing the very programs, services, and systems meant to support us.” 

As a Black man, I have often felt the weight of massive, invisible barriers to accessing resources and opportunities that should inherently be available to me and others who look like me. From school support services, such as counselors who could guide me toward achieving my educational goals, to safe spaces for discussing challenges with therapists or counselors, my experience has been one of limited access. While these services might seem readily available to many, my reality — and that of many others in my community — was starkly different. 

As I transitioned into community organizing in my adult life, I came to understand a critical factor contributing to these barriers: the lack of representation among those designing the very programs, services, and systems meant to support us. When decision-makers lack lived experience or an understanding of the socio-economic realities faced by Black and Brown communities, the resulting solutions often miss the mark. Moreover, the absence of diversity extends beyond race and ethnicity to include gender, sexual orientation, class, disability, and other intersecting identities. 

These missing perspectives in social services, health care, mental health, education, and other county systems exacerbate disparities. Even well-intentioned efforts to address these issues often fail to go beyond surface-level solutions. Entrenched employees, skilled in maintaining system functionality, can struggle to envision alternative approaches due to the rigid, bureaucratic processes they operate within. Furthermore, the voices of those most impacted by barriers are either excluded or tokenized, preventing the fundamental rethinking required to address systemic inequities effectively. 

Co-production offers a powerful solution that must go beyond superficial gestures like surveys or one-off consultations. The lived experiences and expertise of those directly impacted must drive the development of solutions. It must encompass not only values but skills that promote inclusive participation, shared power and responsibility, transparency, capacity building and building on assets, health and reconciliation, compensation of lived experience, and evaluation and accountability. By collaborating with individuals who intimately understand the barriers they face, county systems can create more efficient and effective processes that meet the real needs of diverse communities.  

Having trained co-production to counties and organizations for many years, including with the Transformational Change Partnership (TCP), the most common challenges I see are: 

Challenges in County Systems 

  • Lack of Representation: Insufficient diversity in staff and leadership roles. 
  • Exclusion of Marginalized Voices: Processes often fail to meaningfully include the perspectives of marginalized communities. 
  • Procedural Focus: A tendency to address problems as procedural rather than people-centered, such as focusing on fee schedules or assessments rather than geographic access to services. 
  • Cultural Competence Deficits: Staff may lack cultural competence, relevance, and humility when serving diverse clients. 
  • Client Partnership Overlooked: Failure to recognize clients as essential partners in program and service design. 
  • Siloed Operations: Departmental silos create service bottlenecks that disproportionately affect clients. 
  • Inadequate Data Collection: Limited focus on collecting data about the experiences of underrepresented clients with the greatest needs. 
  • Absence of Advisory Bodies: A lack of diverse client stakeholder advisory groups to guide and evaluate services and processes. 

TCP works directly with county leaders to address these barriers, providing tailored support to dismantle outdated structures and replace them with participatory models.

Implications for Practice: Turning Principles into Action  

Co-production requires ongoing commitment, reflection, and adaptation. Below are practical steps organizations can take to embed co-production into their systems: 

  • Build Relationships, Not Transactions: Invest time in building genuine, trust-based relationships. 
  • Start with Intentional Conversations: Establish a dedicated community advisory group to review and guide strategies, programs, and service; create a space where community members feel safe sharing their perspectives. 
  • Deep Engagement: Develop processes that deeply engage client stakeholders to identify barriers and co-create solutions. 
  • Cross-Departmental Training: Conduct cross-departmental trainings with community stakeholders on cultural competence, humility, relevance, and sensitivity, fostering shared understanding and equitable practices. 
  • Commit to Transparency: Enhance transparency and communication about program development, implementation, and evaluation to improve accessibility and understanding for clients and families. Be clear about the purpose of community involvement and how contributions will influence outcomes. 
  • Empower Frontline Staff: Address internal power dynamics by empowering frontline staff to influence changes in processes and services, supported by management and leadership. 
  • Capacity Building: Partner with third-party trainers to build the capacity of community stakeholders, equipping them to collaborate effectively with county staff and leadership. 
  • Measure What Matters: Implement robust data tracking systems to capture and regularly evaluate the experiences of underrepresented clients, using this information to drive continuous quality improvement in services and co-production. 

A Collective Responsibility 

Co-production is a cultural shift in how we approach collaboration and governance. It calls for humility, patience, and a willingness to share power. And the rewards are undeniable: stronger policies, healthier communities, and systems that are truly reflective of the people they serve. Through initiatives like the Transformational Change Partnership, we are witnessing the tangible benefits of integrating community voices into system-level decision-making. The journey isn’t easy, but it’s one worth taking — together. 

Additional Resources

Slay, J. & Robinson, B. (2011) In this together: building knowledge of co-production, New Economics Foundation, London.  

Slay, J. & Stephens, L. (2013) Co-production in mental health: A Literature Review, New Economics Foundation, London. 

McClinton et al. (2024) Co-Production Competencies, California Institute of Behavioral Health Solutions & Sacramento County. 

Authors

Sidra Ahmad
Ryan McClinton 

Sidra Ahmad, MS 

Behavioral Health Associate in Strategic and Equity Initiatives

California Institute of Behavioral Health Solutions 

Ryan McClinton 

Diversity and Equity Consultant

Clayborn Consulting  

References 

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  5. Julia Slay, Ben Robinson. In this together: building knowledge of co-production. New Economics Foundation. Published online July 2011. ↩︎
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