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ChristineTappan
is the direc-
tor of Strategic
Management at
APHSA and liaison
to the APHSA Local
Council.
Kelly Harder
is the
director of Dakota
County Human
Services and chair
of the APHSA Local
Council.
Policy&Practice
August 2016
16
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
as self-assessment of need (indi-
viduals knowwhere they need to
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
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
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
■
Sustained attention on
fatherhood engagement
■
Commitment to defining and
tracking of a set of common
indicators across all well-being
and health domains