P&P April Issue 2018

The Magazine of the American Public Human Services

Association April 2018

What It Takes Creating a Modern and Responsive H/HS System

TODAY’S EXPERTISE FORTOMORROW’S SOLUTIONS

contents www.aphsa.org

Vol. 76, No. 2 April 2018

features

departments

8

12

3 President’s Memo

We Build Well-Being from the Ground Up

5 Editor’s Note

Changing the Narrative

6 Locally Speaking

Chippewa County, Wisconsin: Hope-Healing-Health

24 Technology Speaks

State Health Information Guidance on Sharing Behavioral Health Information

26 Legal Notes

Codifying the Use of Dolls and Diagrams as Testifying Aids for Children in Abuse Cases

Igniting the Potential Part 2: Supporting and Enhancing the Child Protection Workforce

Preparing Origin Selecting Disaster Recovery as a Cloud Service for Oregon’s New Child Support Enforcement System

27 The Role of a Guardian Ad Litem in a

Termination of Parental Rights Proceeding

28 From the Field

New Staff Training Approach Supports Utah Families in Escaping Poverty

16

20

29 Association News

2018 NAPIPM Call for Papers

30 Staff Spotlight

Christy M. Hines, Director of Policy & Local Strategy

36 Our Do’ers Profile

Kelly Harder, Community Services Director in Dakota County, MN

Traditional Case Management Is a Commodity Mobility, Analytics, and Interoperability Drive Better Outcomes

Weighing the Impacts The Potential Positives and Negatives of Expanding Work Requirements Across Multiple Health and Human Services Programs

Cover Illustration by Chris Campbell

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April 2018 Policy&Practice

APHSA Executive Governing Board

Elected Director Brenda Donald, Director, DC Child and Family Services Agency,

Chair David Stillman, Assistant Secretary, Economic Services Administration, Washington Department of Social and Health Services, Olympia, WA Vice Chair and Local Council Chair Kelly Harder, Director, Dakota County Community Services, West Saint Reiko Osaki, President and Founder, Ikaso Consulting, Burlingame, CA Leadership Council Chair Roderick Bremby, Commissioner, Connecticut Department of Social Paul, MN Treasurer

Washington, DC Elected Director

Susan Dreyfus, President and CEO, Alliance for Strong Families and Communities, Milwaukee, WI Elected Director David Hansell, Commissioner, NewYork City Administration for Children’s Services,

NewYork City, NY Elected Director

Anne Mosle, Vice President, The Aspen Institute and Executive Director, Ascend at the Aspen Institute, Washington, DC

Services, Hartford, CT Affinity Group Chair

Paul Fleissner, Director, Olmsted County Community Services, Rochester, MN

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Policy&Practice April 2018

president‘s memo By Tracy Wareing Evans

We Build Well-Being from the Ground Up

A t our upcoming National Health and Human Services Summit (May 6–9 in Crystal City, VA), we will officially unveil our “Strategic Playbook,” which is the guidebook for our members’ action plan for the next five years. We are energized to share the next phase of our collec- tive commitment to advancing the potential of all people in all places. Informed by our members, partners, and staff—and approved by our Executive Governing Board—the Strategic Playbook is designed to keep a laser focus on the core mission of the Association, assure our work is aligned with the desired future state of the field, connect us through common tools and language, and provide clear direction for how each of us—in our respective and collec- tive roles—can best contribute. I am excited to share some of the highlights of the new Playbook here. The Playbook is shaped by our newly adopted vision and mission statements: Mission: The American Public Human Services Association advances the well-being of all people by influencing modern approaches to sound policy, building the capacity of public agencies to enable healthy families and com- munities, and connecting leaders to accelerate learning and generate prac- tical solutions together. And, it is grounded in a core set of guiding principles for how we— individually and collectively as an organization—can be expected to behave (see What Guides Our Work, page 31). Vision: Thriving Communities Built on Human Potential

preventive and early interventions that enable all families to live healthy lives and thrive in their communities. Building on the theory of change that has emerged over the past five years, we have applied our shared learning into a dynamic “Theory of Action” that guides the steps and strategies we take daily, with and through our members and partners, to deliver on our value proposition (see above).

The Playbook illuminates the shared belief of leaders across the country that health and human services are a cor- nerstone to building a strong, dynamic, and healthy nation made up of thriving communities. Through model frame- works and common approaches, such as social determinants of health, whole family approaches, and the Human Services Value Curve, we are on a shared journey together—focused on moving the health and human services systems upstream to effective

See President’s Memo on page 31

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April 2018 Policy&Practice

Vol. 76, No. 2

www.aphsa.org

Policy & Practice™ (ISSN 1942-6828) is published six times a year by the American Public Human Services Association, 1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2018. All rights reserved.This magazine may not be reproduced in whole or in part without written permission from the publisher.The viewpoints expressed in contributors’ materials are the authors’ own and do not necessarily reflect the policies or views of APHSA. Postmaster: Send address changes to Policy & Practice 1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036

Advertising Natasha Laforteza ads_exhibits@aphsa.org

President & CEO Tracy Wareing Evans Editor Jessica Garon jgaron@aphsa.org Communications Consultant Amy Plotnick

Subscriptions Darnell Pinson

Design & Production Chris Campbell

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Human-Centered Design: Putting Family at the Center of Our Work Innovating for the Future: Maximizing Modern Tools and Platforms The Destination Matters: Achieving Better Health and Well-Being Collective Discovery: Co-Creating Generative Solutions for the Future

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Policy&Practice April 2018

editor‘s note By Jessica Garon

Changing the Narrative

W hat it takes… I’m sure this state- ment creates a laundry list of thoughts for all of us. Many of these thoughts would probably overlap with others, while some are unique to each of us based on our present and past experiences. A caseworker’s mind might be drawn immediately to the vital “here and now” and to thoughts like empathy and courage. For me, not getting to interact daily with those we all seek to serve, I think of what could help make my communication work more effective and one of these things aligns with Tracy’s column in this issue—a discussion of our Strategic Playbook, which was shaped by APHSA’s new vision and mission statements. Framing. We’ve discussed framing before in Policy & Practice. It’s a process that is so critical to our work that it helps to revisit it fre- quently, especially because it’s so hard to accomplish. As defined by the FrameWorks Institute, framing is a process of making choices about what to emphasize—and what to leave unsaid. Using some of their original research in the health and human services realm, we know that human potential is something that we all value. We also know that we all share a common desire to build a good life for ourselves and those we love. By using construction metaphors, we can tap into things like the importance of having the necessary tools to build a strong foundation which proves to be an effective way to show (i.e., frame) how health and human services can promote well-being. Thriving Communities. Through working with you, our members, we know that providing a wide range of services and support to help all people

As champions for change, we must put our heads together to ensure we get a little closer to that place every day. And by changing the narrative from “safety net” to “well-being,” from “entitlement” to “common needs,” and most important, from “them” to “us,” we might just get there a little faster. Have you and your team employed effective framing recently? What else comes to your mind when you think about “what it takes?” As always, we’d love to hear from you—let’s build our thriving communities together!

be healthy and well can ultimately result in thriving communities. As health and human services profes- sionals, you have the ability to help build and maintain these thriving com- munities from the ground up. By combining all of this, a new, effectively framed vision statement guides us to what we want to become: THRIVING COMMUNITIES BUILT ON HUMAN POTENTIAL. Sure, our work could continue without the proper framework, but why go down that road when we now know a better way? To influence policy, we must first shift mindsets with new narratives that show the true impact of health and human services on all of us. It’s not just an investment in one person, or one family, but an invest- ment in our communities. Finding and sharing more productive ways to understand this will help drive us to our desired future state.

Jessica Garon , Communications Manager at APHSA, can be reached at jgaron@aphsa.org.

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April 2018 Policy&Practice

locally speaking By Larry Winter

Chippewa County, Wisconsin: Hope-Healing-Health

C hippewa County, WI, has been a member of APHSA’s Peer-to- Peer Health and Human Services Integration Institute. For this issue’s Locally Speaking , Chippewa County Department of Human Services Director Larry Winter has provided insight into their county initiative and institute project efforts by answering the fol- lowing questions. 1 Describe Chippewa County and the Chippewa County Department of Human Services. Chippewa County is primarily rural and is home to 63,000 citizens located approximately 100 miles east of Minneapolis, MN, and 200 miles northwest of Madison, WI. The county offers excitement and adventure year round and is home to nation- ally known companies, including Mason Shoe, Jacob Leinenkugel Brewing Company, and Chippewa Springs Water; and internationally known computer technology compa- nies Cray Inc. and Silicon Graphics Incorporated. The county has abundant natural resources for those who love the outdoors, including bike and ski trails, snowmobile and ATV trails, picturesque parks, acres of pristine forest lands, and fish-laden lakes and streams, camping, golfing, and opportunities to view birds and other wildlife. The Chippewa County Department of Human Services (DHS) employs 80 staff serving citizens from birth to the end of life. In 2016, the department touched the lives of 30,977 through our services, not including individ- uals and families receiving multiple services. Like many other locations

ALICE , an acronym for A sset L imited, I ncome C onstrained, E mployed, are households that earn more than the Federal Poverty Level (FPL), but less than the basic cost of living for the state (the ALICE Threshold). Combined, the number of poverty and ALICE households (42 percent) equals the total Wisconsin population struggling to afford basic needs. How Many Households Are Struggling in Wisconsin?

29%

Poverty

ALICE

58%

Above AT

13%

below threshold for a survival budget of $24,504 or less for a single adult, and $54,348 or less for a family of four. According to the ALICE Report, the county also rates poorly in Affordable Housing (46/100), fair in Job Opportunities (60/100), and fair in Community Resources (52/100). We wanted to find a way to think about human services differently in our journey toward better results for our community. We joined APHSA to help us along this journey. What is Chippewa County DHS doing to address the social conditions in the county? The department is learning how to engage the larger eco-system through the lens of the Human Services Value

across the country, the county con- tinues to experience an increase in the citizen need for services. The highest need areas are mental health, sub- stance abuse, child abuse, and aging. Chippewa County DHS continues to address issues at the individual and family level by connecting citizens to programs and services. Why did Chippewa County DHS become a member of APHSA? Despite our efforts, the health and well-being of the county has not been improving. According to the United Way’s ALICE (Asset Limited, Income Constrained, Employed) 2016 Report, 2 we learned that a sur- prisingly high portion, 42 percent of households in the County, are at or

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Policy&Practice April 2018

toward a new horizon. The committee defined the problem supported by citizen feedback and we arrived at a future state: “Partner with families and communities in Chippewa County to facilitate Hope, Healing, and Health to address root causes of challenges facing children, families, and commu- nities.” The guiding principles of the future state are: „ „ Creating holistic and family- driven social and health services systems that strengthen the family’s resources „ „ Building trusting relationships „ „ Eliminating institutional barriers „ „ Developing integrated service systems The committee is in the process of completing the plan and begin- ning implementation that will lead toward our desired future state. Earl Nightingale once quoted, “All you need is the plan, the road map, and the courage to press on to your destination.” Our purpose is a true partnership with families and com- munities in Chippewa County to facilitate hope, healing, and health to address root causes of challenges facing children, families, and com- munities. Everyone has been gifted with strengths, talents, and a heart. We intend to ensure system barriers do not impede any human being in our county from the opportunity to reach his or her full potential. To discuss or explore the ways in which the APHSA OE team can provide support to leaders or teams looking to advance opportunities in their own organizations or communities, contact Emily Campbell, OE Director, at ecampbell@aphsa.org. Reference Notes 1. Winter, L. & Senn, K. Hope, Healing & Health in Chippewa County WEAU 13 News Interview. January 17, 2018. http://bit.ly/2GqXU9y 2. United Way of Wisconsin, Wisconsin ALICE (Asset Limited, Income Constrained, Employed) Study of Financial hardship. Summer 2016. http://bit.ly/2uhYMIR

our current status, we’ve learned that our citizens don’t view the purpose of our human services system as truly in service of the community: “The system serves the system.” Although the “system” espouses that it serves individuals and families based on their hopes and dreams, little evidence supports this belief in practice from the citizen’s perspec- tive. The facilitation process thus far has helped us define our collective vision of Hope, Healing, and Health; understand where we currently are in reference to our vision; and identify a plan moving forward informed by the root causes that have been barriers to moving our community toward hope, healing, and health. Learning the framework of the HSVC is also new for the committee and gaining expertise through APHSA allows us to accel- erate our learning. Without coaching us toward the north star, we most likely would be shooting the arrow and missing our target due to gaps in our learning. The CYFC conducted an assessment by interviewing a randomized sample of individuals and families receiving services to gain their perspective on how they view the support of the “system.” The perception of service effectiveness from individuals and families is: „ „ Paperwork and lack of coordination among agencies—“you repeat the same thing over and over again, even for sub-divisions of DHS” „ „ Inconsistencies due to multiple staffs and turnovers „ „ Waiting period, two years before receiving services—“by the time we got the services, things were already out of control” „ „ Lack of centralized information systems „ „ Not having enough one-on-one time with staff „ „ Not being listened to, lack of personal relationship „ „ Needs for peer-to-peer interactions to exchange ideas/information „ „ Mostly good relationship with staff—sometimes mixed feelings These perceptions of individuals and families caused the committee to criti- cally face reality and begin a process

Curve (HSVC). For us, the HSVC is a lens to help us better understand our current efforts and work smarter rather than harder. If we can col- laborate with our community partners better and integrate the underlying needs of families in service design, the HSVC shows that we can expect better outcomes for our citizens with fewer resources expended. Crucial to this process of trying to collaborate and get at the barriers and enablers of health and well-being in Chippewa, is working alongside the community. The County Health and Human Service Board, in November 2014, approved the formation of the Children, Youth, and Families Committee (CYFC). The committee is a partnership compromised of government; education; business; law enforcement, United Way; faith-based, nonprofit, health care, public health, legal, education, and economic development organizations; and consumers of services. Our com- mittee is committed to incrementally moving our county partners toward collective action with a shift toward whole-person and family-centric service design. Historically the county partners collaborate on some policy, programs, and team-based case planning. However, through technical and financial support from the Peer- to-Peer Integration Institute through APHSA, with sponsorship from the Kresge Foundation, the committee has taken the initial steps toward real- izing this vision. How does the committee intend to incrementally move county partners to make this shift? We intend to make progress through truly listening and inviting feedback from our citizens and implementing a systematic change management process. Through the Peer-to-Peer Institute, we have engaged an APHSA Organizational Effectiveness (OE) facilitator and learned to utilize APHSA’s OE unit’s change management framework called DAPIM (Define, Assess, Plan, Implement, and Monitor). Through this process of defining the desired future state of our community with our community and then assessing

Larry Winter is the Director of the Chippewa County (WI) Department of Human Services.

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April 2018   Policy&Practice

The Health and Human Services Workforce

Supporting and Enhancing the Child Protection Workforce PART 2

innesota is one of a handful of states whose child welfare system is structured as a state-supervised and county- administered model. Minnesota’s system spans a large geographical area made occurred in several states, Minnesota experienced a high profile child death resulting in heightened public criticism and news coverage portraying the state’s child welfare workforce as being remiss in the protection of Minnesota’s children. The public nature of the scrutiny catapulted the system into reform guided by 93 systemic and practice change recommendations borne out of a Governor’s Task Force on the Protection of Children. up of 87 counties and 11 federally recognized tribes. In 2014, as has

By Jamie Sorenson and Traci LaLiberte

counties modified their hiring require- ments to accommodate the dwindling pool of eligible professionals while others sought to make their county more attractive through salary incen- tives and workplace supports. In the end, a statewide intervention designed to support the counties in high-quality hiring practices was needed. Other jurisdictions and field-based research have found great success in using video-based realistic views of the work in child welfare as a screening and hiring tool. Realistic Job Previews (RJP) serve to screen in the right candidates by making sure that professionals have a thorough understanding of the job— the good and the challenging. RJPs also serve to screen out other candi- dates, helping them recognize that this may not be a good career fit. While it may seem to defer the number of can- didates moving forward in the process, it reduces unnecessary and expensive turnover, which ultimately harms children and families being served. We created the new Minnesota RJP, 1 in partnership with state and county partners across rural, suburban, and metropolitan areas. County agencies have been incredibly pleased with this new tool and the accompanying strat- egies for its implementation in their hiring practices. WORKFORCE STUDY In 2015, state and county agencies and the University of Minnesota’s Center for Advanced Studies in Child Welfare partnered to conduct a workforce study to understand the well-being and stability of the current workforce. The study examined child welfare professionals’ intent to stay in their current positions, move to dif- ferent child welfare positions, or leave the field altogether. It also looked at the impact of reform efforts as associated factors in staying, moving, or leaving. E-mail surveys resulted in a state- wide response rate of 44 percent. Analysis showed that 83 percent of respondents experienced secondary traumatic stress, 53 percent actively sought employment outside of their current position in the past year, and 67 percent reported being over- whelmed with their current job duties.

The Minnesota Department of Human Services was charged with leading the engagement of multi- system partners and stakeholders in what has been three years of rigorous and rapid reform to Minnesota’s child welfare system, extending beyond just child protection. To improve child and family outcomes, reform efforts have been targeted toward three primary child welfare system practice domains: child maltreatment report intake and screening, critical incident review of child fatalities and near fatalities, and child welfare workforce development, stability, and wellness. As anticipated, increased media attention and reform efforts in intake and screening have resulted in more children and families entering Minnesota’s child welfare system, further exacerbating an already taxed system and workforce. As we enter our fourth year of child welfare reform in Minnesota and reflect upon the lessons learned, sus- tainable collaborative partnerships have emerged as a primary con- tiguous thread driving our successes. Leveraging both structural and rela- tional frameworks to merge expertise and resources is redefining who we are as a child welfare system and creating new possibilities for the development and ongoing support of our workforce, which ultimately drive improved outcomes for children and families. For the purposes of this article, we will describe four specific initia- tives used to ignite the potential for improvements in the workforce: Development and use of a realistic job preview, execution of a workforce sta- bility study, study and implementation of a new training academy (structure and content), and the implementation of the Collaborative Safety Model. Each initiative incorporated key input from multiple partners, with alternating leadership roles, using an implementation science framework. REALISTIC JOB PREVIEW With increasing rates of turnover, pending retirements in a senior work- force, and mounting caseloads due to the reform-induced influx of referrals, Minnesota experienced a child welfare caseworker hiring frenzy. Some

Igniting the Potential is a recurring theme for 2018. In each article, we introduce our readers to various efforts underway in the H/HS workforce. If your organization has a compelling story to share about how you are supporting and advancing the H/HS workforce, we would love to hear from you. Contact Jessica Garon at jgaron@aphsa.org. Igniting the Potential

Jamie Sorenson is the Director of Child Safety and Permanency Division at the Minnesota Department of Human Services

and President of the Executive Advisory Committee of the National Association of Public ChildWelfare Administrators.

Traci LaLiberte is the Executive Director of the Center for Advanced Studies in ChildWelfare in the School of Social Work at the University of Minnesota.

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Policy&Practice April 2018

Despite these significant numbers, 79 percent of respondents reported their intention to remain in their position in the next year and provided rich con- textual responses for ways in which employees could be better supported through reduced administrative func- tions and smaller caseloads, improved quality of supervision, and devel- opment of strategies for employee well-being inclusive of attending to secondary traumatic stress. More than 10 percent of the recom- mendations from the Governor’s Task Force on the Protection of Children were directly related to workforce training and development. The impli- cation of all other practice reform measures is that thoughtful and com- prehensive training must be developed to ensure uniform adaptation and fidelity to new practices. One of the first steps was a comprehensive review to make necessary modifications to a newly developed set of child welfare worker competency statements. Given the considerable training and profes- sional development focus from the task force, stakeholders from various public, tribal, and nonprofit agencies gathered to examine statewide training systems in other states, their structures, pedagogies, and curricula. Through this interagency partnership, the team completed numerous site visits with other child welfare training systems. Sites were selected for their similarity to the Minnesota child welfare system or their innovative and successful training practices. Building upon current strengths in local training and incorporating STATEWIDE TRAINING ACADEMY

the Statewide Training Academy is a highly anticipated entity. COLLABORATIVE SAFETY MODEL Historically, Minnesota’s approach to critical incident review in child welfare leaned more toward increased workforce stress and blame than it did to identifying systemic challenges and necessary practice improve- ments to avoid harmful outcomes for children and their families. To shift this culture to one of greater balance, considering both safety and account- ability, Minnesota sought expert help from Collaborative Safety, LLC co- founders Dr. Scott Modell and Noel Hengelbrok. They are described as pioneers in applying safety science to the field of child welfare by the Federal Commission to Eliminate Child Abuse and Neglect Fatalities. Their work in Minnesota has expanded well beyond critical incident review to incorpo- rate the principles of safety culture and accountability more broadly to practice, including, but not limited to, social work supervision, workforce wellness, and systems of continuous quality improvement. As statewide implementation of the Collaborative Safety critical incident review process and use of the tools began, we made extraordinary efforts to engage professionals at all levels of

information gathered from training system site visits as well as a research and practice literature review, a design for a new Minnesota Child Welfare Training Academy was developed. The design incorporates four elements, including system structure, training, training enhancements, and evalua- tion/accountability (see Figure 1). The University of Minnesota’s Center for Advanced Studies in Child Welfare partnered with county representatives and other child welfare stakeholders to package the Statewide Training Academy design with an accompa- nying budget into a proposal for review and consideration by the Minnesota legislature. The proposal is supported by public and private entities with con- siderable support from the employees’ union and community advocates. As a foundational component to reform implementation and a cultivation and support of a strong workforce,

Minnesota’s realistic job preview and wisdom learned from the workforce study allow us to connect to those inquiring about working in Minnesota’s child welfare system and also to those who are attending daily to children and families touched by Minnesota’s system.

See Igniting the Potential on page 30

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April 2018   Policy&Practice

Selecting Disaster Recovery as a Cloud Service for Oregon’s New Child Support Enforcement System Preparing ORIGIN RIGIN

By Lorrin King, James Wollenweber, and Vishal Prabhu

I

n the event of an unforeseen interruption, it’s critical that an organization have the ability to resume operations and success- fully recover the IT infrastructure expeditiously. For organizations without an up-to-date and tested disaster recovery system in place, recovery following a disaster tends to be quite challenging and expensive. As part of Origin’s imple- mentation, the Oregon Department of Justice’s new child support system, the department collaborated with Deloitte to help evaluate and select a quality disaster recovery solution to enable continuity of services. The Origin of Origin The Oregon Child Support Program ment system for its aging mainframe solution. The solution chosen through this process combines the base California system with the document generation, reporting, and business intelligence functionality from the Michigan and New Jersey systems. Deloitte Consulting LLP was selected by the Department of Justice (DOJ) to design, build, and implement Oregon’s hybrid solution, Origin. conducted analysis to research, evaluate, and choose a replace-

A Disaster Recovery Solution for Origin Given the mission criticality of the child support business processes along with the sensitivity of hosted data, the DOJ was determined to set up and maintain a quality disaster recovery (DR) solution for the new system that could enable continuity of services for its customers while minimizing cost and improving maintainability of the infrastructure for the agency. Policy compliance was another key driver for the DOJ identifying a DR solution for Origin. The state- wide Department of Administrative Services policy on business conti- nuity planning 1 mandated DR for the DOJ, as well as for all agencies under direct authority of the Governor, to ensure that critical business functions

Table 1. Available DR Option

DR as an On-Premise Service

DR as a Cloud Service Government Cloud Hosting Provider ■„ Hosting services available from leading government cloud providers ■„ Hosting and managed services required to meet federal and state com- pliance requirements

State Data Center

DOJ’s Information Services

Third Party Vendor

■„ State data center responsible for pro- viding on-premise hosting and managed services in a virtual environment ■„ Secondary site maintained at Helena, MT for DR

■„ On-premise virtual hosting solution main- tained by DOJ ■„ Managed services provided internally by DOJ

■„ Government, private, and hybrid hosting services provider located in Beaverton, OR ■„ Secondary site maintained in AZ for DR

DOJ and Deloitte Take a Deep Dive The next step in the process was to identify key evaluation criteria for hosting and implementing the DR system. To do this, the DOJ collabo- rated with Deloitte. The teams used their extensive health and human services experience to perform business impact analysis and identify system recovery point objectives (RPO) and recovery time objectives (RTO) for DR require- ments for the child support system project. In addition, Deloitte provided in-depth understanding of various federal and state regulatory policies for DR (e.g., Authority to Connect

and public services continue under any conditions. This policy set forth guidelines requiring all state agencies to develop, implement, test, and maintain business continuity plans, thereby driving the need for DR systems. Weighing the DR Options There are two primary options available for hosting the DR system— on-premise and cloud. Table 1 contains the specific options that were evalu- ated: DR as an On-Premise Service (State Data Center, DOJ’s Information Services, or Third Party Vendor) and DR as a Cloud Service (Public Cloud Hosting Provider).

Lorrin King is the Chief Information Officer at the Oregon Department of Justice.

Table 2. Evaluation Criteria

James Wollenweber is the Technical Manager for the Child Support

Cost of Ownership

■ Solution must be cost effective in maintenance mode (i.e., during normal operations when DR is on standby) as well as in operational mode (i.e., during the event of a disaster) ■ Reasonably moderate RPO/RTO requirements do not warrant the need for a “hot site” in either on-premise or cloud model, which allow maximizing on cost savings offered by the cloud’s data replication and pay-as-you-use model ■ Solution must be able to handle man-made and natural disaster events by providing redundant capabilities at an alternative geographical location ■ Solution must be able to support the RPO/RTO requirements for the system ■ Internal Revenue Service (IRS) 1075 prescribes security and privacy controls to protect Federal Tax Information (FTI) data ■ IRS established the Safeguards Program to ensure that government agencies receiving FTI data apply these controls through periodic audits ■ Solution must meet FedRAMP/IRS 1075 requirements, based on NIST 800-53 ■ Statewide policy mandates the development, testing, maintenance, and annual update of a business continuity plan (State Policy #107-001-010) ■ Solution must be able to handle loss of power, network, equipment failure, and data loss, among other areas ■ The technology for the solution should align with the DOJ’s future-state IT roadmap

System Project (Origin System) at the Oregon Department of Justice.

Robustness of Solution

Federal and State Compliance

Vishal Prabhu is a Specialist Leader and Application Architecture Assessment Champion at Deloitte Consulting LLP.

Vision Alignment

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Policy&Practice April 2018

Figure 1. Qualitative Comparison of Cloud versus on-Premise Hosting

of cloud versus on-premise as hosting solutions for DR.

[ATC] from the Centers for Medicare and Medicaid Services [CMS], Pilot Entry and Exit Controls, HIPAA Contingency Plan Compliance). This experience, coupled with Deloitte’s role as system integrator on the project, uniquely positioned Deloitte to collaborate with DOJ and its hosting provider to identify considerations for an effective DR solution. Through this collaboration, DOJ determined the following evaluation criteria were necessary in making a decision on hosting a DR solution. Note: Given the similarity in char- acteristics of the three options under on-premise, they were consolidated into a single on-premise model for evaluation against DR as a cloud service. DR in the Cloud Following an extensive evaluation of the information collected for the two DR hosting options, it was determined that hosting DR in the cloud was the right decision for Oregon’s DOJ and Origin. Put simply, leveraging cloud technology allows organizations to focus on their core business processes instead of on IT infrastructure. Figure 1 shows a comparison of some of the qualitative characteristics

legal structure. Certain services may not be available to attest clients under the rules and regulations of public accounting. This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte shall not be responsible for any loss sustained by any person who relies on this publication. Reference Notes 1. Statewide Business Continuity Planning, Policy #107-001-010. www.oregon.gov/ das/Policies/107-001-010.pdf 2. Federal Cloud Computing Strategy. https://www.dhs.gov/sites/default/files/ publications/digital-strategy/federal- cloud-computing-strategy.pdf 3. CMS Cloud Computing Standards. www. cms.gov/Research-Statistics-Data-and- Systems/CMS-Information-Technology/ InformationSecurity/Downloads/RMH_ VIII_32_Cloud_Computing.pdf Copyright © 2018 Deloitte Development LLC. All rights reserved.

TheTakeaway Agencies should envision the DR in cloud hosting effort as a low-risk, high-return launch pad toward realizing their vision of eventually migrating their nonproduction and production IT infrastructure to the cloud. Implementing DR in the cloud provides agencies with a wide variety of potential benefits, ranging from significant reduction in capital expen- diture by leveraging the massive scale discounts offered by public cloud to improvement in robustness of the DR system. To help agencies achieve these benefits, the federal government has instituted a Cloud-First strategy that encourages cloud adoption for new investments. 2 The CMS Computing Standards also recognize the cloud as a reliable disaster recovery envi- ronment for providing business continuity. 3 As used in this document, “Deloitte” means Deloitte Consulting LLP, a subsidiary of Deloitte LLP. Please see www.deloitte.com/ us/about for a detailed description of our

15

April 2018 Policy&Practice

Traditional Case Management Is a Commodity Mobility, Analytics, and Interoperability Drive Better Outcomes

By Stuart Venzke, Mary-Sara Jones, and Paul Dommel

Q

uite simply, developing a modern and responsive health and human services (H/HS) system requires modern and responsive information technology (IT) systems. It is not enough to collect, process, and display client and case information, as traditional case management systems do. A modern and responsive system must help agencies sense and respond to changing circumstances in real time, rather than waiting for a report that merely describes what happened months ago. Modern H/HS agencies must recognize the H/HS system extends well beyond the walls of the governmental H/HS agencies, to include community-based and other organizations with which clients engage. And a modern and responsive H/HS system must enable and empower human services profes- sionals within their workflows, as they are assisting clients or managing cases, so they view it as a tool that helps them do their job, rather than an impediment to it. This is well beyond the scope of traditional case management, which has become a commodity. To build a modern and responsive H/HS system, agencies should focus on developing three key capabilities supported by technology: interoperability, analytics, and mobility.

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Policy&Practice   April 2018

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April 2018   Policy&Practice

Traditional Case Management Is a Commodity To say traditional case manage- ment is a commodity does not mean it is unimportant. Traditional case management systems were designed to standardize and automate func- tions previously performed by hand, such as eligibility determination and risk assessments, to improve efficiency and consistency across an agency. Historically, when we thought of “better” case management systems, we thought in terms like “easier to use,” “more functionality,” “lower cost,” and “reduced maintenance.” Of course, those are still important and worthwhile attributes. Modern case management systems should be stable, well-designed, flexible, and

their circumstances across the H/HS enterprise, so human services pro- fessionals have a more holistic understanding of their client. It also draws relevant information from non- traditional sources, like police systems or weather records, to provide impor- tant contextual data—for example, the police may receive a report of domestic violence that alerts a child welfare caseworker that a related child welfare case requires imme- diate attention. It allows clients to share information, based on informed consent, with agencies and providers safely and securely. The County of San Diego has adopted this approach and it is making a difference. The county is focufo- cused on delivering person-centered service, which requires the integra- tion of services and information from child welfare, social services, mental health, probation, substance abuse, and others. The solution is designed to help the county fight recidivism by providing incarcerated persons with the services they need to succeed in the community, support individuals with multiple needs access the services available to them, and strengthen- services for kids by providing a more complete understanding of the child and the family. The County of San Diego did not start with technology. Instead, the county began by analyzing business needs and building relationships across service areas. It had a vision, developed supporting use cases, and obtained buy-in from stakeholders. Technology simply provides a scalable collaboration environment for the service providers to engage with their customers. Using sophisticated matching algorithms and an intuitive portal, staff get a holistic view of each individual and family from a life- style, social, and clinical perspective. Caseworkers are able to make more informed decisions, include the family in tracking those decisions, and more easily collaborate across agencies. An analytical H/HS system not only collects client and case data; it uses the data to provide actionable insights to clients and workers. Today, most

easy to use. But those attributes are table stakes—every case management system should have them—and none of those things has a direct impact on improving client outcomes. While case management systems are great at collecting information and applying rules, they are historically weak at providing H/HS agencies and human services professionals with meaningful, actionable insight to improve client outcomes in real time. Yet that is exactly what a modern and responsive H/HS system requires. It is not enough to collect client and case data for a year, analyze it for another six months, then issue a report describing or even explaining what happened a year and a half ago. Human services professionals need information at the point of service to support data-driven decisions about what to do here and now for this client. Toward Modern, Responsive Human Services Platforms To improve client outcomes, clients and human services professionals need insights appropriate to their immediate circumstances, gleaned from multiple sources, and delivered when and where they are needed. To that end, modern and responsive H/HS systems must have three strategic capabilities. They must be: „ „ Interoperable —providing a clear view of clients and their circum- stances across the H/HS enterprise and beyond, rather than relying on client data siloed in a multitude of disparate systems. „ „ Analytical —providing ongoing, meaningful analysis not just at the aggregate or program level, but also at the client level, to provide actionable insights that inform deci- sion-making by clients and human services professionals. „ „ Mobile —equipping and empow- ering both clients and human services professionals to be more efficient, more effective, and more responsive. An interoperable H/HS system breaks down the traditional siloed approach to delivering services. It provides a clear view of clients and

Stuart Venzke is a U.S. State and Local Health and Human Services Leader at IBM.

Mary-Sara Jones is a U.S. State and Local Health and Human Services Leader at IBM.

Paul Dommel is the Global Leader for Government Health and Human Services at IBM.

See Case Management on page 32

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Policy&Practice April 2018

The Potential Positives and Negatives of Expanding Work Requirements Across Multiple Health and Human Services Programs t he Impacts By Russell Sykes

of the current administration is to expand work, education and training preparatory to work, or other forms of community engage- ment requirements as conditions of eligibility for numerous health and human services programs. For the first time it would expand work requirements to Medicaid and strengthen current minimal ones in subsidized public housing. The administration’s emphasis on the importance of work for noncustodial parents has recently led to the federal O ce of Child Support Enforcement to issue guidance to state child support agencies clarifying that it is eager to grant exemptions requests to allow states to use incentive funds to finance employment and training e orts for that population. A major emphasis

for adults without disabilities. 4 Eight states have pending waivers (AR, AZ, IN, KS, ME, NH, UT, and WI). CMS has granted waivers to Kentucky and Indiana. 5 There is no differing opinion among states that employment for those who can work is both economically and socially beneficial. Existing health and human services programs support the elderly, people with disabilities, and children, and they comprise the majority of program caseloads. The majority of work-eligible adults in public benefit programs already work, but there is a concerning and not insignificant percentage of nondis- abled, nonworking adults enrolled in public benefit programs. As a matter of public policy, they need our atten- tion. The numbers could be as high as nine million or more, but estimates tend to be point in time, subject to some dispute and are likely to count duplicate beneficiaries across several programs. Our member states must be both intentional and cautious in properly designing programs to help this population achieve success through various approaches that combine expectations and consequences. What are the potential opportunities and pitfalls of expanding work require- ments in all programs, particularly Medicaid and public housing? General Arguments in Favor of ExpandedWork Requirements The idea of reciprocity, where public agencies provide benefits through multiple programs based on certain expectations that work-capable adults make reasonable efforts to improve their situations, has become more widely accepted. As one of the social determinants of health, employment may not only improve economic conditions, it may also build social capital by connecting adults to colleagues and other contacts. It can also prevent social isolation and improve both physical and mental health outcomes. In Medicaid, recent state and federal government efforts have somewhat reduced the previously soaring growth in costs to a more manageable level. But the program remains a huge

While work-eligible adults must register for work in SNAP E&T, states currently have leeway to define their SNAP E&T programs as voluntary or mandatory except for a population known as able-bodied adults without dependents (ABAWDs) ages 18–49. ABAWDs are required to find work or participate in defined work-related activities for 20 hours weekly, or receive benefits for only three months in a 36-month period. The administration’s budget looks to expand SNAP work requirements in general and make them manda- tory in most instances. As part of this effort, the U.S. Department of Agriculture Food and Nutrition Service issued an Advance Notice of Proposed Rulemaking in the February 23, 2018 issue of the Federal Register (Vol. 83, No. 37, p. 8013), soliciting comments from states and other organizations on further expansion of ABAWD work requirements. Similarly, as of this writing, legislation expected to emerge from the House Agriculture Committee as part of Farm Bill reauthorization was to be introduced no later than April and have a stronger focus on SNAP work requirements. Limited programs to promote work at public housing authority discre- tion have existed for those receiving direct subsidies or having housing choice vouchers since 1985, but they have been extremely small and experi- mental. A January 2018 study by the Urban Institute details the limited information available on the efficacy of such efforts. 1 The administration’s budget proposal for FY 2019 would require as many as 32 hours weekly of work or other activities as a condi- tion of eligibility for the 26 percent of nonworking, nondisabled residents of public housing. 2 The inclusion of Medicaid in the panoply of programs with work/ community engagement require- ments is the newest proposal from the administration. A January 11, 2018 Guidance Letter to States from the Centers for Medicare and Medicaid Services (CMS) encourages states to apply for Section 1115 waivers 3 to, at their option, implement work and/or community engagement requirements in Medicaid as a condition of eligibility

This stronger emphasis on work accelerated in 1996 with the enact- ment of the Personal Responsibility and Work Opportunity Reconciliation Act and the creation of the Temporary Assistance for Needy Families Program (TANF). Experiments by states through federally granted waivers to require or encourage work for able- bodied adults in the previous Aid to Families with Dependent Children program set the stage for the 1996 legislation creating TANF, which made work a condition of eligibility for benefits, with sanctions imposed for failure to comply. It required states to place 50 percent (90 percent of two-parent families) of those classified as able bodied either into a job or one of 12 federally defined qualifying activities for 30 hours weekly (20 hours for those with young children and 35 hours for two- parent families). The administration’s focus on work was reinforced through the president’s fiscal year (FY) 2019 budget proposal, which would expand these requirements and demand that states spend 30 percent of their TANF Block Grant and their state-required maintenance-of-effort funds on work- related activities. The concept of work in return for benefits found its way into the Supplemental Nutrition Assistance Program (SNAP) in 1998, when the Employment and Training Program (SNAP E&T) was initiated. Current federal funding since 2002 comes through two avenues, a limited pool of 100 percent federal funds for states and a 50–50 percent match pool of federal and state (including private/ philanthropic) funds.

Russell Sykes is a Senior Fellow at the American Public Human Services Association.

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