Policy & Practice February 2015

The Magazine of the American Public Human Services Association February 2015

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TODAY’S EXPERTISE FORTOMORROW’S SOLUTIONS

contents www.aphsa.org

Vol. 73, No. 1 February 2015

features

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20

18 Months in Massachusetts A story of adaptive leadership success against the odds

Decoding the Value Curve Championship-level change efforts are advancing throughout the health and human service system today

12

24

Leading Change It's about looking around—and looking forward

What's Shaping the Path Forward for Human Services? Key factors impacting the road ahead

28

16

NEICE Envisioning the future for the placement of children across state borders

Leading Change Partnerships to improve the child welfare workforce

departments

3 Director’s Memo

33 Partnering for Impact Project SOARS partners with local agencies to help young children reach new heights 34 Technology Speaks A strong PMO is more crucial than ever before

38 Staff Spotlight Mas Tedesse Harris,

Presenting innovative and evidence- informed strategies that respond to APHSA members’ priorities

conference coordinator

40 Our Do’ers Profile

5 WashingtonViewpoint Realpolitik and Reconciliation: What to watch for in 2015

William A. Hazel, Jr., Secretary of Health and Human Resources for the Commonwealth of Virginia

32 Association News

36 Legal Notes

Updates from NASTA and NSDTA

Videotaping child sexual abuse investigation interviews

Cover photograph via Shutterstock

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February 2015 Policy&Practice

INDUSTRY PARTNERS Platinum Level

APHSA Board of Directors Officers President Raquel Hatter , Commissioner, Tennessee Department of Human Services, David Stillman, Assistant Secretary, Economic Services Administration, Washington Department of Social and Health Services, Olympia, Wash. Treasurer, Local Council Representative Kelly Harder, Director, Dakota County Community Services, West Saint Paul, Minn. Secretary Tracy Wareing, Executive Director, APHSA Past President Reggie Bicha, Executive Director, Colorado Department of Human Services, Denver, Colo. Director Eric M. Bost, Assistant Director of External Relations, Borlaug Institute, Texas A&M University, College Station, Texas Director Mimi Corcoran, Independent Consultant, Harrison, N.Y. Director Susan Dreyfus, President and Chief Executive Officer, Alliance for Strong Families and Communities, Milwaukee, Wis. Director Reiko Osaki, President and Founder, Ikaso Consulting, Burlingame, Calif. Affiliate Representative, American Association of PublicWelfare Attorneys Ed Watkins, Assistant Deputy Counsel, Bureau of Child Care Law, New York State Office of Children and Family Services, Rensselaer, N.Y. Nashville, Tenn. Vice President

INDUSTRY PARTNERS Platinum Level

Vision: Better, Healthier Lives for Children, Adults, Families and Communities Mission: APHSA pursues excellence in health and human services by supporting state and local agencies, informing policymakers, and working with our partners to drive innovative, integrated and efficient solutions in policy and practice.

ToChallengeandEquipOrganizations toTurnGood Intent intoMeasurableChangebyRelatingE orts toOutcomes Silver Level ToChallengeandEquipOrganizations toTurnGood Intent intoMeasurableChangebyRelatingE orts toOutcomes Silver Level

KPMG International’sTrademarks are the sole property of KPMG International and their use here does not imply auditing by or endorsement of KPMG International or any of its member firms. KPMG International’s Trademarks are the sole property of KPMG International and their use here does not imply auditing by or endorsement of KPMG I ternational or ny of its member firms.

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Policy&Practice February 2015

director‘s memo By Tracy Wareing

Presenting Innovative and Evidence-Informed Strategies that Respond to APHSA Members’ Priorities

A s we embark on another year and welcome new members to APHSA, I thought it might be helpful to highlight some of the tools and products we have developed with and through our members and partners. Guided by our Pathways framework, we have a broad array of resources and technical assistance to help our members improve in the priority areas they have identified through innovative and evidence-informed strategies to front-line practices and services, and to the organizational capacity they need to deliver them effectively. Pathways: Our Collective Destination Our Pathways framework was developed with our state, local, and affiliate leaders, and defines the desired future state for the health and human service field. Clarity about the impact and underlying strategies we seek to achieve guides the ongoing resource-building and technical support work we do with our members. Pathways is framed by the following dimensions (see http://www.aphsa.org/content/ APHSA/en/pathways.html): Š Š Four priority outcomes: Gainful employment and independence; stronger individuals, families, and commu- nities; healthier individuals, families, and communities; and the sustained well-being of our youth. Š Š Five practice strategies: Prevention, Early Intervention, Bridge Support, Capacity-Building and Sustainability— arranged in a general sequence of intervention aimed at getting the right service at the right time for the right duration, ultimately reducing reliance on government services. Š Š An array of foundational supports for these practice strategies, including: >> Flexible financing —that allows federal support to go where it is most effective, taps resources from other sectors, and moves beyond outdated cost-allocation restrictions; >> A new accountability paradigm —focused on meaningful outcomes, continuous improvement, monitoring for results, cross-government coopera- tion, and full use of modern data-analysis tools; >> A modern technological platform —that supports integrated, enterprise solutions across programs, departments, and levels of government;

>> A prepared workforce —that is deployed strategically, has the tools and technologies it needs, and partners effectively with the larger stakeholder community; >> Empowered clients through effective engagement —that employs equitable and appropriate responses to each person’s and family’s situation, evidence-informed strategies, and the knowledge that engaged communi- ties and families can foster positive and lasting change. Š Š A set of general markers describing the desired future state (see my article on p. 12 for a full description). APHSA’s PrimaryTechnical Service Platforms: Helping Members Achieve the Pathways Desired State The National Workgroup on Integration (NWI) (http://www.aphsa.org/content/APHSA/en/pathways/NWI. html) NWI resources and technical support are used by member agencies to guide their systems through transformative stages of change and progress. Developed since 2010 with input from leading practitioners, universities, and industry partners, the primary NWI frameworks include the Health and Human Services Value Curve and Stages, the Health and Human Services Business Model and Maturity Matrix Factors, and a range of guidance and tools targeted at evolving the business model factors and addressing common barriers to progress. NWI resources and services are most often used by high-readiness health and human service systems, including cross-program, cross-jurisdiction, and public-private partnership initiatives. The Organizational Effectiveness (OE) Handbook and Consulting Service (http://www.aphsa.org/content/APHSA/en/resources/ OE.html) The APHSA OE practice supports any continuous improve- ment, innovation, or transformation effort, by strengthening the underlying drivers of organizational readiness, capacity, and performance upon which innovative or transformative strategies are built and sustained. OE has been developed with and through our members since 2004, resulting in a very positive external evaluation that demonstrates a

See Director’s Memo on page 39

Photograph via Shutterstock

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February 2015 Policy&Practice

Vol. 73, No. 1

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 web site at www.aphsa.org. Copyright © 2015. 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

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Policy&Practice February 2015

washington viewpoint By Ron Smith

Ron Smith is APHSA’s director of legislative affairs.

Realpolitik and Reconciliation What to Watch for in 2015

R ealpolitik is the concept of policy development based primarily on practical considerations as opposed to an explicit ideological doctrine. The 114th Congress convened in January with both chambers under the control of Republicans but lacking sufficient power to override a presidential veto. The dominant question for 2015 is if the new congressional leadership feels that they have a mandate from the electorate to enact the policy positions their candidates expressed during the 2014 elections, or will they choose to pursue legislation based on the prac- tical calculation that the president still is a major player when it comes to policy development? Judging from the debates that took place during the 2014 lame-duck session, it would appear that members of both chambers are readying for a fight with the president in 2015. To fully understand the strategy that the majority in Congress is likely to adopt, and the potential limita- tions of that strategy, it is important to have a basic understanding of some of the legislative tools available to the congressional leaders. While a congressional majority might want to confront the president on a number of policies, repeal of the Affordable Care Act (ACA) is well known to be high on the list. Repeal of the Affordable Care Act also represents an excellent case study of the limitations facing Congress when enacting policies opposed by the president. The Senate is Ground Zero The first maxim to keep in mind is that a determined majority in the House of Representatives always gets

The Byrd Rule, named for West Virginia Senator Robert Byrd, plays a major role in congressional budget negotiations.

caucused with them, thus having a de facto margin of 60 votes. Prior to then, the last time a party had a 60-vote margin was in 1977. 2 With this coun- try’s current political alignment, it is unlikely that either party will hold a 60-vote margin in the foreseeable future. Senate rules still require a 60-vote hurdle for most legislation, 3 but it is critical to understand that certain bills, by law, are not subject to a Senate filibuster. Thus, it only takes 51 votes for the current majority to pass legislation strongly opposed by the minority. Other than those few opportunities, the majority is five votes short of passing much of their legisla- tive agenda. Moreover, for the next two years President Obama has the

its way. 1 The rules of the House ensure that the Speaker, by definition the leader of the majority party, has suf- ficient tools at their disposal to get any bill passed as long as their caucus agrees. The minority party can use certain procedures to delay passage of measures they disagree with, but for the most part all they can do is force a vote or two on motions that are doomed to fail. This reality explains why the Senate is often ground zero on highly controversial issues. A deter- mined majority in the Senate is not guaranteed success unless it has at least 60 votes. The last time either party held 60 seats in the Senate was a very brief time in 2009 when Democrats had 58 seats and two independent members

Photograph by Alex Wong

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February 2015 Policy&Practice

spending in one area and decrease it in another as long as the net effect complies with the reconciliation instructions. The House and Senate Budget Committees combine various com- mittee recommendations into a single reconciliation bill. They are not per- mitted to make substantive changes to other committees’ recommendations for how to comply with reconciliation instructions. In past years, members of Congress realized that reconciliation bills could be used as a “Christmas Tree” 11 to enact all kinds of provisions that might not otherwise be enacted. The practice so distorted the original purpose of the reconciliation that the Senate enacted specific restrictions on what could be included in a reconciliation bill. While these restrictions do not apply to the House, they apply to amendments and conference reports and they represent a de facto limitation on what the House can include in its reconciliation bill. In 1985, the Senate adopted the Byrd Rule, named after its principal sponsor, Sen. Robert Byrd (D-WV). The Byrd Rule was codified in 1990 as Section 313 of the Budget Act. 12 The Byrd Rule’s purpose is to keep extraneous provi- sions out of reconciliation legislation. The rule allows any senator to object (using a point of order) to any provi- sion that is “extraneous.” Extraneous is defined as any one of six criteria. If a Byrd Rule point of order is upheld in the Senate, it is stricken from the bill unless 60 votes are in favor of waiving the point of order. To be considered extraneous, a pro- vision typically would fall under one or more of the following criteria: 13 1. A provision that produces changes in mandatory spending or revenues that is merely incidental to the legis- lation of that provision; 2. A provision increasing mandatory spending or reducing revenues (i.e., increasing the deficit) in a commit- tee’s title of the legislation that is not in compliance with its reconciliation instructions; 3. A provision not in the jurisdiction of the committee that reported the title of the legislation; 4. A provision that would increase the deficit in a fiscal year that is beyond

into compliance with the provisions of a budget resolution. 8 Congress will consider reconciliation legislation, therefore, only if it has been able to adopt a budget resolution and then only if that resolution contains recon- ciliation instructions. A budget resolution is different from most bills. First, it is a concurrent resolution, which means that while it must pass the House and Senate, it is not sent to the president for approval. 9 Furthermore, it is also a privileged legislative vehicle in the Senate that cannot be filibustered, and only needs a simple majority to pass. The budget resolution establishes aggregate spending levels that limit the amount of spending for discretionary programs available to both appropriation com- mittees for the coming fiscal year. It can increase or decrease limits on man- datory spending and revenue levels. To ensure that targets for mandatory spending and revenues are met, the budget resolution may require specific congressional committees to report bills to meet those targets, which is indicated in a reconciliation bill. It is critical to understand that there are limits as to what can be included in reconciliation legislation. Such legisla- tion can affect mandatory spending, revenue (i.e., taxes), and debt-limit levels. 10 Other legislative items— such as setting specific discretionary spending or enacting legislation that does not affect federal manda- tory spending programs—cannot be enacted through reconciliation. The budget committee, in preparing the budget resolution, can require separate reconciliation bills to deal with manda- tory spending, with revenue, and with the debt limit, or they can combine them into one reconciliation bill. While the reconciliation instructions direct specific committees to achieve certain net levels of spending or revenue changes, they cannot specify the policy changes the committees may use to achieve those changes. The instructions can only direct commit- tees to increase or decrease mandatory spending or revenue by a certain amount over a specific time period. Reconciliation instructions are for net amounts of change in mandatory spending—a committee can increase

power to veto bills that would require 295 votes in the House and 66 in the Senate to override, far more votes than either chamber is likely to achieve. 4 It is more likely that Republicans will use their new Senate majority to repeal or modify highly unpopular portions of the health care law, or at least force Democrats to go on record on those issues. Faced with the reality that repealing the ACA is likely beyond their control, there are still elements of the bill that remain subject to congressional attack. The most likely provisions of the ACA the majority will focus on include the: Š Š Medical device tax Š Š Tax on health insurance premiums Š Š Employer-mandate penalty Š Š Definition of the full-time work week at 35 hours, and Š Š Individual tax for not purchasing qualified health insurance. As previously mentioned, there are legislative vehicles that are not subject to a Senate filibuster and thus are the most likely vehicles the majority will use to address some of these issues. The budget reconciliation process may be familiar to many who follow congressional action, but few fully understand its purpose and its limitations. What is Budget Reconciliation? A reconciliation bill is considered “privileged” under Senate rules. 5 The reconciliation process was created as part of the Congressional Budget Act (CBA) of 1974. 6 That law stipulates that the Senate needs only a simple majority to pass a reconciliation bill and that the bill is subject to just 20 hours of debate. Over time the scope of how reconciliation bills are used has changed in many ways. Most important, it is the use of the recon- ciliation, and the budget process in general as the CBA established it, that gives Congress the “dominant role in policymaking.” 7 The reconciliation process was origi- nally intended to provide Congress with a vehicle for considering adjust- ments to mandatory spending, revenues (i.e., taxes), and the debt- limit and to bring the federal budget

Photograph via Shutterstock

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Policy&Practice   February 2015

in reconciliation legislation. The same is true for the employer penalty for failing to provide health insurance. 2010 Déjà Vu? Few people will remember that Democrats used the reconciliation process to fully implement the ACA. In 2009 the House and Senate passed different versions of a health care bill. The Senate passed their bill with 60 votes, just enough to overcome a Republican filibuster. In August of that year, Sen. Edward Kennedy (D-MA) died, leaving Senate Democrats with only 59 votes. When Sen. Scott Brown (R-MA)—a Republican—won the special election in February 2010 to fill the remainder of Kennedy’s term in office, the Democrats lost the votes needed to pass a health care confer- ence report. As a result, the House of Representatives was forced to pass the Senate bill without any amendments, which they did in March 2010. The bill, as passed by the Congress and signed by the president, had several problems that legislators usually would have worked out in the process of adopting a conference report. In order to fully implement the new law, Democrats used the reconcili- ation process to correct the problems in the bill signed by the president. 15 By using reconciliation, Democrats were able to avoid a Senate filibuster and get the bill to the president. What to Watch for in 2015 In 2015, the Republican majority in the House and Senate will have a several opportunities to attack policies supported by President Obama. Reconciliation has the advantage of not being subject to a filibuster. But other bills, such as increasing the statutory debt ceiling, can be used because they are considered “must pass” bills and are therefore difficult for Democrats to filibuster or for the president to veto. Appropriation bills are other “must pass” avenues, which Republicans will certainly use to attack the president’s executive action on immigration. 16 There will be a number of oppor- tunities in early 2015 for Congress to consider critical bills, any of which might be used as vehicles to attack at least some element of the ACA. March

may be a pivotal month in which many of these issues could come to a head. The current statutory limiting on the debt ceiling is due to expire on March 15, 2015. 17 On that same day, the current “doc fix” expires. This issue involves the reimbursement rate for physicians under Medicare and using the Sustainable Growth Rate (SGR) formula contained in the Balanced Budget Act of 1997. 18 Due to an anomaly in the formula, Congress has had to pass numerous bills to suspend the formula to avoid reduc- tion of reimbursement rates. The latest such bill was enacted in April 2014 19 and suspends the SGR until March 15, 2015. Finally, last December, the House passed an appropriation bill 20 for the Department of Homeland Security that funds that department until February 15, 2015. Conclusion The use of reconciliation and other “must pass” bills provide Congress with several opportunities to pass leg- islation that will force the president into a difficult position of vetoing a “must pass” bill or sign it into law. The realpolitik question remains, to what degree will the new majority powers in Congress want to pursue ideologically based policies, or will they instead choose to adjust their position and work to pass legislation the president might sign? majoritarian institution, the Senate is structurally designed to protect the rights of the Minority.” Basic Training: Senate Rules from a House Perspective, House of Representatives Rules Committee. http:// rules-republicans.house.gov/Educational/ Read.aspx?ID=8 2. Party Divisions in Congress. http:// en.wikipedia.org/wiki/Party_divisions_ of_United_States_Congresses 3. Invoking Cloture in the Senate, Christopher M. Davis, Analyst on Congress and the Legislative Process, Reference Notes 1. “While the House is designed as a

the budget window the reconcilia- tion legislation is covering; and/or 5. Legislation that makes changes to Social Security. A provision can be considered “extra- neous” for its impact on mandatory spending, even if that provision might have a significant impact on policy. Simply because the impact is incidental does not mean the impact would not be significant. How Congress Might Use Reconciliation in 2015 Given the limitation imposed by the Byrd Rule, many of the ACA provi- sions are likely to be beyond the scope of the reconciliation legislation. In order to fulfill campaign promises, it is highly possible that Congress will move early with straightforward legis- lation offering a full repeal of the ACA. In the last Congress, the House voted 54 times to repeal or amend the ACA. Such legislation would probably be fili- bustered in the Senate even though its Democratic leaders were highly critical of filibusters when they had control of that body. Democrats might decide not to filibuster a direct repeal of the ACA knowing that the president would cer- tainly veto the bill. While the Republicans cannot use reconciliation for a full repeal of the ACA because there are provisions of the act that would be considered extraneous, there are still numerous vital sections of the act that could be included in reconciliation legislation, particularly the individual mandate. When the Supreme Court ruled that the ACA was constitutional, it did so because the individual mandate was determined to be a tax. Supreme Court Chief Justice John Roberts, author of the majority decision, concluded, “that the individual mandate must be con- strued as imposing a tax on those who do not have health insurance, if such a construction is reasonable.” 14 If the individual mandate penalty included in the ACA is considered a tax, it could be repealed as part of a reconciliation process. Additionally, all the various tax provisions in the ACA, including the medical device tax and the tax on health insurance, could be included

Congressional Research Service. November 25, 2013. http://www. senate.gov/CRSReports/crs-publish.

cfm?pid=%26%2A2%3C4QLS%3E%0A 4. Veto Override Procedure in the House and Senate, Elizabeth Rybicki, Analyst See Viewpoint on page 39

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February 2015   Policy&Practice

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Policy&Practice February 2015

“Talk is cheap. Let’s go play.” —JOHNNY UNITAS, QUARTERBACK, PRO FOOTBALL HALL OF FAME Johnny Unitas was a highly suc- cessful professional quarterback who’d have a hard time even making a profes- sional football roster today. His height, strength, speed, and throwing power did not, shall we say, statistically check the right boxes. Cut in rookie camp by the team drafting him out of college, Unitas recovered with great resilience and resolve against long odds, understanding that actions and results speak louder than perceptions or expectations. His general leadership philosophy is captured in his standard six-word pep talk to his Colts team- mates, made leaning against the locker room doorway before many games they would play together, including many hard-won championships. Championship-level change efforts are advancing throughout the health and human service system today. At the Kresge Foundation’s 2014 Human Services Grantee Policy Convening, a meeting of national health and human service associations, the group was commenting on the upbeat feeling in the room despite the environmental challenges we all continue to face. Our conclusion was that the well-conceived actions and innovations being driven today by real-world communities are defying the odds. We see improved performance and successful change being driven by well-planned, action- able product and service strategies, known in football as a “playbook.” But plays need to be diagrammed before they’re practiced and used on game day. So what’s supporting these winning efforts to develop better playbooks and drive actions and inno- vations around the country?

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February 2015 Policy&Practice

Part of the answer lies in an ini- tiative that was launched in 2010, co-sponsored by Harvard, Accenture, and APHSA, where agency, federal government, and private provider leaders have come together annually to understand and advance the Health and Human Services Value Curve (see graphic at right). Now when I think of Harvard or summit meetings, I don’t immediately think of Johnny Unitas and his adage about talk being cheap. And when I first saw this Value Curve four years ago, I worried that it would result in a bit more concept than action. Even the best designed playbook looks like a bunch of symbols that mean nothing to anyone who hasn’t taken the field to learn through action what it all means. But four years later, we see many examples around the country of agencies and their partners decoding this Value Curve—communicating about it more confidently, applying the framework through a range of actionable strate- gies, and winning stakeholder support for advancing through its four stages. At its core, the Value Curve describes how health and human services are provided to those we serve at four pro- gressive levels of value, each building from and expanding the consumer value delivered at the more formative levels: 1 At the regulative level , con- sumers receive a specific product or service that is timely, accurate, cost-effective, and easy to understand. Many agencies and systems around the country are focused on achieving efficient and effective service within a specific program area, and to a large extent this is good for consumers. But we know the value limitations of sending

Efficiency in Achieving Outcomes

Generative Business Model

Integrative Business Model

Collaborative Business Model

Outcome Frontiers

Regulative Business Model

Effectiveness in Achieving Outcomes

product and service flexibility, and enhanced service delivery. This is all geared toward supporting people to prevent problems upstream versus fixing or recovering from them down- stream. This all requires redefining casework practice and skills, pro- viding real-time technology tools for caseworkers, establishing new forms of data and analysis geared toward problem prevention, and instituting highly adaptive program design and funding mechanisms. 4 At the generative level , dif- ferent organizations providing various products and services are joining forces to make the consumer’s overall environment better for them, resulting in value that is broader and more systemic than an individual or family might receive directly. At this stage of value, agencies, with their partners, focus on general consumer advocacy and co-creating capacity at a community-wide level as a means to meet consumer needs. This requires collective efforts targeted at community-level infrastructure building, and enhancing societal beliefs and norms about government, in general, and those we serve, in partic- ular. This ultimately results in greater commitment to leveling the playing field, plugging everyone into the

those we serve through many program doors, engaging them within a limited program scope, or focusing primarily on program compliance and related output goals as measures of our own performance and value, whether or not these outputs are having the desired consumer impact. 2 At the collaborative level , con- sumers “walk through a single door” and have access to a more complete array of products and services that are available “on the shelf.” At this level, agencies with their partners focus on cross-programmatic efficiency and effectiveness, which often require operational innova- tions like unified intake and eligibility systems, cross-program service plans that address multiple consumer needs, and shared data platforms or protocols to support these integrated services. Certainly a big step up in value for con- sumers, but not the best we can do. 3 At the integrative level , products and services are designed and customized with input from consumers themselves, with the objective of best meeting their true needs and enabling positive outcomes in their lives. The focus in this stage is on more consulta- tive consumer engagement methods,

Phil Basso is the deputy executive director for Strategic Communications and Organizational Effectiveness at APHSA.

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Policy&Practice February 2015

members about how to transform themselves, often through real-world accounts of how some of our members are achieving transformative progress today. This is a shift from the regulative Effectiveness (OE) technical assis- tance practice was launched in 2004, replacing a classroom-based, fixed leadership development curriculum. OE was, for years, thought of as a side- table experiment that survived by paying for itself and contributing net revenues to our bottom line. Today, our change management and continuous improvement products and services are being integrated into most of our strategic initiatives. OE has evolved from experience, directly consulting with our members, through custom- ized projects that they help design and adjust as we work together, similar to consultative casework approaches. The OE practice has now been exter- nally evaluated, with very promising findings about its impact on sustained change, performance, service quality, and outcomes. This is a movement from the regulative to the integrative stage for the association. Prior to 2010 we were often reluc- tant to partner with industry, private providers, other associations, and on the international scene, though experi- ments with each were occurring. These partnerships were often viewed as “nice-to-have’s, but not essential” or only important for additional funding purposes. Today, such partnerships are integrated into our board roster, primary conferences and committees, and broader influence strategies. A broad range of partners is now working with us to better understand how we can all drive transformative change at the community level and in our society as a whole. This is a movement from the regulative to the integrative and generative stage for APHSA. Our hope is that more examples emerge of agencies and their commu- nities decoding the Value Curve and putting their related playbooks into practice—delivering greater levels of value and creating better communities for all. If you decide to take the field, know that we’re lacing up our cleats with you. to the integrative stage for us. The APHSA Organizational

and to advocate for “more money and less rules” within current programs. The federal level of the system was thought of as an arbiter of our state members’ funds and of the rules they did or didn’t like. Our focus has since shifted to policy and program inte- gration and innovation targeted to improving consumer outcomes. Since local agencies often drive innovation within existing policy and program structures, we now view them as the We see many examples around the country of agencies and their partners decoding this Value Curve— communicating about it more confidently, applying the framework through a range of actionable strategies, and winning stakeholder support for advancing through its four stages. primary incubator of what would form the basis for later broad-scale reforms. Our focus at the federal level has evolved to cross-programmatic and cross-jurisdictional influence, toward enabling increased service integration and more preventive service designs at the consumer levels. This is a shift from the regulative to the collaborative and integrative stage for us. Prior to 2010, APHSA did not have a formal strategy. We’ve since developed formal strategic plans and rebranded ourselves, with Pathways emphasizing a vision for the future of our field—how we can all work together to create a desired future state of our organiza- tions and practices that better impact outcomes for those we serve. Our Innovation Center has focused on pro- moting promising ideas and strategies throughout the field, such as alterna- tive financing and adaptive leadership practices. Our National Workgroup on Integration is designed to explicitly support Value Curve movement within communities across the United States. We are now communicating with our

community as a whole, and employing practical solutions that work.

Thinking of Johnny U’s little pep talk, here are three straightforward, real-world examples of how agencies are decoding and applying the Value Curve today: l An agency improving SNAP benefits accuracy and timeliness builds upon its successes by partnering with community-wide program providers to meet together with consumers on Saturdays. After a series of these “open houses,” the various partners develop protocols to engage with common consumers and determine service eligibility more holistically. This is a strengthening of regulative value and a shift from the regulative to the collaborative stage. l A local agency with multiple program responsibilities decides to affect out- of-home service and placement rates state, city manager, and the courts to blend and braid funds and customize service plans at the individual and single-family levels. It is guided by the view that “families are the best experts of what they need to thrive.” This is a shift from the regulative to the integrative stage. l A county-wide citizen service board is established to develop shared outcomes goals and determine the predictive “risk factors” it will track to ensure the community as a whole for children, youth, and its aging population, by working with the evolves in a way that benefits all citizens, including those experi- encing acute risk factors. Improved infrastructure projects and economic development efforts with greater taxpayer support result in their col- lective efforts. This is a shift to the generative stage of value. APHSA’s Journey through the Value Curve Stages Since 2010, APHSA has created a new playbook and taken the field under the leadership of our governing Board and executive director, Tracy Wareing. Prior to that time, the policy and program emphasis here was to help our agency members understand and navigate the current ones better,

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February 2015   Policy&Practice

What’s Shaping the Path Forward for Human Services?

Key factors impacting the road ahead

By Tracy L. Wareing

Photograph via Shutterstock

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Policy&Practice   February 2015

Three years ago we introduced our member- driven Pathways initiative, which provides a guiding framework to transform the human service system and hold all of us accountable for results that matter: gainful employment and independence; stronger and healthier families and communities; and the sustained well-being of youth. 1 Pathways envisions a system that delivers the right service at the right time for the right duration, ultimately reducing dependency on government services and achieving better outcomes at lower costs. It uses modern business models, maximizes information through analytics, and values innovation, all with a resolute focus on doing what works. It is supported by flexible funding streams that incentivize improved outcomes and is marked by strong partnerships that reach across sectors and leverage resources and strengths of the full community.

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The Office of Management and Budget (OMB) is using its bully pulpit to embed evidence-informed practices into government-led services and to jettison programs that have not proven to move the needle. On the ground, localities are leveraging these oppor- tunities with an eye on sustainable population-based health and well- being; their experiences and results are likely to impact whether these policy directions are here to stay. Modern Platforms States are taking an intentional look at their current business functions and the change needed to reach their 21st century enterprise-wide vision for interoperable and integrated systems. Technological advances are playing a key role in modernizing human service delivery, from the growing use of mobile apps to equip customer and workers with easy access to the tools and services they need, to the use of predictive analytics software to identify families at risk and uncover fraud. With these technological advances comes the need for skills, capabili- ties, and values never before required of those in social work. Agencies are hiring analytics experts, reevaluating hiring practices, and revamping devel- opment and training approaches in order to build the capacity of the work- force to use the data before it. On the flip side, the Millennial workforce grew up in environment where technology and its enabling abilities are second nature. If our sector is to attract them to the human service workforce, these tools and modern approaches must become standard fare. The biggest game changer for mod- ernization of human services may have come from an unlikely source—an exception to the OMB A-87 cost alloca- tion circular, designed to leverage the new Medicaid eligibility and enroll- ment systems for the human services side of the house. CMS’s recent decision to extend the Exception to December 2018 is a catalyst for states looking to modernize their systems. 3 APHSA, with and through our members, led the national push for this extension. It is a historic moment—allowing states additional time to complete the design, development, and implementation of

their integrated eligibility and enroll- ment systems.

Across the country, APHSA members are turning this vision into a reality for the communities they serve. As high- lighted in this article, six factors are helping human service agencies shape the path forward, manage for collec- tive impact, and ultimately, transform the system: l Š new integrated policy opportunities; l Š greater access to modern platforms ; l Š intentional space for innovation labs ; l Š an investment in real outcomes ; l Š application of science to human service delivery; and l Š co-creation through transformative partnerships. Each of these is briefly addressed below, followed by how APHSA is supporting its members’ efforts to understand and apply these factors. Integrated Policy In recent years, there has been an increasing number of demonstration projects designed to integrate service delivery across multiple programs and funding streams. At the national level, many of these efforts are being co-led by two or more federal agencies with the objective of achieving greater interoperability, spurring innova- tive solutions, and better leveraging community supports. 2 In Congress, reauthorization of long-standing programs is being done with renewed interest in exploring how best to link programs with desired outcomes—for example, the $200 million for SNAP Employment and Training pilots included in the reauthorization of the 2014 Farm Bill and various provisions of the recently enacted Workforce Innovation and Opportunities Act.

Innovation Labs I recently heard the word innova- tion described as an “old term that has new prominence,” and that is clearly playing out in human services. Agencies are increasingly focused on how they can embed continuous learning as part of the agency culture. The need to address long-seeded cultures and biases requires inten- tional focus on change management, organizational effectiveness, and read- iness. The ability to innovate and be creative plays a key role in this effort. Innovation laboratories—some as full departments and others with a few designated staff—are emerging at all levels of government, from the White House Office of Social Innovation and Civic Engagement to local human service agencies. San Francisco’s Human Service agency has a “design anthropologist” who is responsible for focusing on the design of the agency and looking for innovation opportuni- ties, identifying solutions quickly, and facilitating their implementation. In Philadelphia, there is an actual inno- vation lab in its City Hall—a physical place where city employees are asked to compare together and focus on inno- vation, ideation, and problem-solving. Investing in Outcomes Agencies are making investments to gain powerful insights into how they are actually performing, identify what works, and shed ineffective programs. By applying business intelligence plat- forms that present the data through specialized reports, caseworkers, supervisors, and top administrators are making better, informed deci- sions. 4 Predictive analytics, through new online tools, are being used to identify at-risk families, understand service gaps (e.g., geographic), and scan for fraud in eligibility and intake systems. High-quality, low-cost evalu- ations in the form of “rapid cycles” are being used to quickly determine whether an intervention is effec- tive and to continuously improve through rapid experimentation. 5 Rapid Cycle Evaluation tests components of a program rather than the whole

Tracy L.Wareing is APHSA’s executive director.

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Key Questions Likely to Impact the Actual Path Forward l What is the tolerance level for government to innovate and be

the science of behavioral economics can be applied to the delivery of human services to rapidly test what “lands” with a customer and achieves the desired behavior. For example, what kind of notice is likely to lead a non-cus- todian to play his or her child support or how can information provided to a parent receiving a child care subsidy ensure that they enroll their child in a high-quality child care setting. Collective Impact There is a growing emphasis on understanding the art and the science of true partnerships and how those partnerships can be force multipliers toward a common agenda. Collective impact requires shared goals and measurements, and a governance and accountability system that reflects a collective—not an individualized— approach. 9 Illinois has produced a Framework for Healthcare and Human Services to assist states in good gover- nance and interoperability, including across public-private partnerships. 10 Local jurisdictions are particularly adept at tapping the natural resources within a community (e.g., San Diego fire departments conducting blood pressure screens to promote preventive care). How APHSA is Supporting its Members along the Transformation Journey Pathways provides a consistent frame for both proactively advocating for modern, integrated policy and responding to what national policy- makers are doing. Whether we seek results-based funding for safe children and strong families by modernizing the financing of child welfare or respond to an NPRM on regulations governing child care, child support or SNAP, Pathways provides the integrated lens by which our members believe policy must be designed if we are to maximize resources and achieve the kind of outcomes that we desire. At APHSA, we are working through our technical assistance platforms—the National Workgroup on Integration as well our Organizational Effectiveness

program or service and helps foster a continuous improvement environment within an agency. Four years ago, the idea of social impact financing (paying for actual outcomes once the outcomes are secured) was largely unknown to human services. Now these financing models are emerging all over the country, with growing interest from service providers eager for funding to help them demonstrate the effec- tiveness of their program and from government agencies interested in finding ways to finance and scale such programs. This is a new place for philanthropic capital to support exploration and help accelerate new models for financing services. National policymakers are interested as well. The Corporation for National and Community Service established the Social Innovation Fund and recently announced $12 million in awards to eight organizations to advance and evaluate emerging models that align payment for human services with verified social outcomes. 6 And leg- islation has been introduced in both chambers of Congress with hearings held on Capitol Hill. Other alternative financing struc- tures are also emerging. Performance Partnership Pilots were recently announced allowing for the blending and braiding of funding aimed at disconnected youth across multiple funding streams—in this case, educa- tion, labor, and health and human services. 7 There are also “pay for performance” measures appearing in legislation such as the recent reautho- rization of the Workforce Innovation and Opportunity Act, which includes provisions for incentivizing better employment outcomes, not just paying for training. Science Science is being applied to human services in ways never imagined. What we know about the development of the brain, especially the long-term impacts of trauma and adversity on children and their parents, is leading to new understanding of how difficult it is to “hear through the noise.” This information suggest that our historical approach to services may have little

impact on someone with impaired adult executive functioning skills (i.e., the cognitive processes located in the prefrontal cortex of the brain that help us self-regulate and plan). For a brilliant explanation of the damage of maternal depression and toxic stress on children’s development and what is needed to support those mothers, I encourage you to listen to a Ted Talk by Dr. Elisabeth Babcock, president and CEO of Crittenton Women’s Union. 8 The science of Behavioral Economics is also impacting human service delivery. Agencies are asking how to adapt tools from behavioral science to improve the well-being of children and families. Behavioral interventions in human service delivery are being tested by a small teamwithin the White House Office of Science and Technology and through the Behavioral Interventions to Advance Self-Sufficiency (BIAS) project at the Department of Health and Human Services. These teams look to identify what small changes in the environment may change behaviors and decisions. Much like marketers work to understand the behavior of consumers, l How do we create the conditions for achieving collective impact, particularly when our procurement and funding structures are outdated? creative? If government fails during a test of innovation will it be allowed to “learn” and “pivot” to shift or change its focus? l Where will technology be the most disruptive? Will government be able to respond? Can government leverage partners in both the private for-profit and nonprofit worlds to position itself to more nimbly adapt to changing technology and maximize new tools, rather than falling behind? l Are we hiring for the values and skills needed to operate in an ever- changing environment requiring high levels of adaptability and analytic skill? Do we understand the generational differences and what they mean for our field?

(OE) practice—to help member agencies fully leverage the Cost

See Pathways on page 38

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February 2015   Policy&Practice