P&P August 2016

relationship between assessment, case planning, and the promotion of well- being. Successful health and human service delivery depends on that keystone—comprehensive, holistic, and prevention-oriented assessments of individual, child, and family needs. Like a keystone, much of what makes an assessment process powerful and effective is invisible. Hidden within a well-designed assessment is a thorough understanding of family strengths and resources, which makes it possible to co-create and implement solutions with the family and community providers. Person-centered planning, combined with ongoing monitoring of changes in family needs and capacities, and shared common client data to the degree possible among multiple community providers, promotes optimal targeting of interventions, enhances the EDO approach, and saves both time and cost by avoiding service duplication. When agencies use these approaches with all families—including those with an array of needs and risk factors—it is possible to maximize successful growth in individual and family self- sufficiency, and to use system resources more efficiently. To create substantive change, many local members are shifting their prac- tices and system infrastructure to use assessment as the keystone within a Practice Model for Well-Being. These agencies are redesigning programs toward an integrated approach, coordinated across systems, with a universal assessment process and holistic casework practice at its center that aims to ensure collaborative case planning and promote self-sufficiency. Local members call this process the Self-Sufficiency Matrix (SSM). Using common, non-clinical language, the SSM allows both the family and the case manager to understand, talk about, and plan around the pillars of family stability and well-being within the Social Determinants of Health context. In order to thrive, all families move through their lives navigating their health, financial well-being, network of relationships, neighbor- hoods (the types of food available in local stores, even the quality of the air and water, and the relative safety of their streets). The SSM provides a

that contribute to well-being, it can be hard to picture all of this at once. Many people are familiar with only a small fraction of what exists in their community—and sometimes the dif- ferent services and systems do not know each other as well as they should and do not interact, making coordi- nation extremely difficult. In recent years, leaders in the fields of human services and health have begun talking about ways to ensure that the separate services are effective, but also that they work together—as a “system of care.” Local member agencies are in varying stages of designing and implementing integrated systems. Some have fully defined intercon- nected systems with moderately sophisticated assessment and service delivery approaches, while others are just beginning to conceptualize their primary entry points or “front doors.” All agree on this ideal set of four elements for a Practice Model for Well-Being: 1. “Every (or Any) Door is Open” entry into the system (EDO), including health, housing, economic assistance, child care or welfare, disability services, corrections, law enforcement, or community-based organizations 2. “Ease of access” strategies, such

go), real-time and robust referral protocols to services (to help people find the best route), streamlined approaches to eligibility determina- tion and compliance with multiple program requirements, including documentation and monitoring 3. Shared screening and decision protocols for all health and human services, which should include, where possible, a collaborative risk and opportunity assessment that uses individual assessment, coupled with predictive analytics framed by social determinants of health, and focuses on core outcomes of safety, health and well-being, and self-sufficiency 4. Casework and service planning that is collaboratively developed, delivered, and able to measure outcomes and impact Assessment as the Keystone of Well-Being: The Self- Sufficiency Matrix When constructing a building, a stone sits at the center of an archway— the keystone that locks all of the building’s pieces together and stabi- lizes its structure. Its role, while not obvious, is critical. One might describe assessments in health and human services as the keystone to building well-being. Over the last decade, substantial evidence indicates a ■ Sustained attention on fatherhood engagement ■ Commitment to defining and tracking of a set of common indicators across all well-being and health domains A set of principles, informed by a body of research and best practices, guide these elements. These principles include: ■ Solid prevention- and strengths- based orientation ■ Two-generation and multi- generation approaches ■ Holistic, person-centered, and customized service planning ■ Both pre-trauma and trauma- informed strategies

as self-assessment of need (indi- viduals knowwhere they need to

Kelly Harder is the director of Dakota County Human Services and chair of the APHSA Local Council.

ChristineTappan is the direc- tor of Strategic Management at APHSA and liaison to the APHSA Local Council.

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Policy&Practice August 2016