Policy & Practice February 2018

The Magazine of the American Public Human Services Association February 2018

Leadership Championing Progress in Our Field Adaptive

TODAY’S EXPERTISE FORTOMORROW’S SOLUTIONS

contents www.aphsa.org

Vol. 76, No. 1 February 2018

features

departments

8

12

5 Editor’s Note

Leading at All Levels

6 Locally Speaking

Establishing Partnerships to Address Social Issues with Older Adults

26 Technology Speaks Using Technology to Fight the Opioid Epidemic

28 Legal Notes

Battling the Cover-Up Culture of Child Sexual Abuse in Schools

29 Legal Perspectives of “Sexual Addiction”

Igniting the Potential Part 1: The Health and Human Services Workforce

Adaptive Leadership Streamlining Processes Before Automation

30 From the Field

Ten Seconds of Being

31 Association News

Unlocking the Power of Human Services to Build Strong Families and Communities

34 Staff Spotlight

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20

Ann Flagg, Director of Collaborative Centers

40 Our Do’ers Profile

Katie Griego, Employment and Benefits Division Director, Colorado Department of Human Services

Championing Progress In Our Field How Human Services Leaders Can Advance Paid Family and Medical Leave

The Power of a Generative Ecosystem Insights from Leaders at the 2017 Harvard HHS Summit

Cover Illustration by Chris Campbell

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February 2018 Policy&Practice

APHSA Executive Governing Board

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 Paul, MN Treasurer Reiko Osaki, President and Founder, Ikaso Consulting, Burlingame, CA Leadership Council Chair Roderick Bremby, Commissioner, Connecticut Department of Social Services, Hartford, CT Affinity Group Chair Paul Fleissner, Director, Olmsted County Community Services, Rochester, MN Elected Director Anne Mosle, Vice President, The Aspen Institute and Executive Director, Ascend at the Aspen Institute, Washington, DC Elected Director Susan Dreyfus, President and CEO, Alliance for Strong Families and Communities, Milwaukee, WI

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.

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Policy&Practice   February 2018

Vol. 76, 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 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

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Policy&Practice February 2018

editor‘s note By Jessica Garon

Leading at All Levels

W hen we first introduced our themes for the year, a few pro- spective authors reached out to ask what we mean by “adaptive leader- ship.” Internally, we’ve been using this term for a few years but this was a gentle reminder that our “latest language” isn’t always on everyone’s radar. The same goes for our most common frames and tools. While a lot of you—especially those of you who are repeat readers—are probably quite familiar with our mindset and the accompanying frameworks like social determinants of health, whole family approaches, and the Value Curve, it’s our job as your membership association to continue introducing and reempha- sizing these concepts that ultimately have the ability to move us toward population health and well-being. So back to answering the question at hand: What is an adaptive leader? As explained by Ronald Heifetz, Founding Director of Harvard’s Center for Public Leadership, “Adaptive leaders diagnose the situation in light of the values at stake, keep the level of distress within a tolerable range for adaptive work, and focus their atten- tion on ripening issues.” Echoing that sentiment at a leadership conference, our President and CEO, Tracy Wareing Evans, said adaptive leadership was “ideally suited to drive creative approaches in complex environments.” With the human services sector so often seeking ways to overcome complex challenges during uncertain times, the ability to adapt is key. It’s also important to understand that you can adapt and lead others through these challenges without having all the answers—sometimes we simply need to guide (or be guided) through the uncertainty at hand.

to you, we can all be leaders in the workplace. Whatever your position empowers you to do, take full respon- sibility for providing the best quality work in every situation. Spend time improving relationships within your own department and then develop and manage relationships across depart- ments. Engage and encourage team members regardless of their position, history, or age and, before you know it, people will be looking to you in times of uncertainty. If we all strive to enable families to live their best lives and reach their full potential, we also need to enable and inspire those around us on a daily basis.

This brings me to my next thought: leading at all levels. I think we all know you don’t have to be the director of your agency or organization to possess and use these valuable skills. Not many people know this, but in addition to my work here at APHSA, I’ve also had the opportunity to teach communication courses at my alma mater. In one of my courses, where we discuss leader- ship skills and styles, I always ask my students if they think leaders are born or made. It will always be an interesting question to me because I’m convinced that there is no right or wrong answer. Someone can certainly become a leader through the process of teaching, learning, and practicing but there’s also no denying that qualities often associ- ated with leadership come easier for some people. And there is no clear-cut answer as to why that might be. No matter what your current job title, the skills you strive to achieve, or the skills that seem to come naturally

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

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February 2018 Policy&Practice

locally speaking By Dan Eggleston and Trish Suszynski

Establishing Partnerships to Address Social Issues with Older Adults

I t’s 11:45 p.m. on a Saturday night and the fire fighters/paramedics assigned to Albemarle County Fire Rescue (ACFR) Medic 8 are en route to 808 Elm Street for an elderly woman who has fallen out of bed and in need of medical attention. Medic 8’s crew is very familiar with 808 Elm Street and Gertrude Smith. Just today, it is the third call to this address and there are still hours to go before the shift ends. The crew members pull up to Gertrude’s apartment, remove the key from the front door lockbox, and go inside after a brief announce- ment—very much like the actions of a family member or a close neighbor. They approach the bedroom and find Gertrude on the floor in a state of panic—exhausted, covered in filth, and embarrassed about her condition. She cannot remember when she fell, but it has been hours. The crew members help her up from the floor and to her wheelchair, clean her up, change the sheets, and tidy up the place. They even make her a sandwich and turn the television to her favorite show. Gertrude loves her fire fighters, because they always respond when she needs them, are polite, and take care of her needs with no com- plaints. She often refers to them fondly as “her boys.” Fire fighters are problem solvers and are very skilled at mitigating complex, technical emergencies. Their compas- sion and focus on customer service makes them a great asset for people like Gertrude Smith. However, older adults like Gertrude often have challenges that, on the surface, may seem simple and straightforward. But a deeper look reveals more complex social issues that

Adult Services at DSS investigates reports of abuse, neglect, and exploita- tion of adults older than 60 years of age with the goal to protect a vulnerable individual’s life, health, and property without a loss of independence. JABA is a nonprofit agency that serves the Charlottesville/Albemarle region by providing an array of services to the aging community. One particular service JABA provides is options counseling, an in-depth conversa- tion with the individual and their family to educate them about the specific resources available for care and services in their community. This process assists the individual in obtaining and maintaining optimum functioning in the least restrictive envi- ronment possible while respecting the individual’s right to self-determination.

require a highly skilled specialist who can assess the situation and get to the root of the problem. Gertrude’s needs exceed that of a single agency and the long-term solution would require a team approach. A group of dedicated fire rescue employees, motivated by their desire to “fix the problem,” formed a task force with the mission of addressing Gertrude’s challenges. Based on prior experience working with county and nonprofit agencies, fire rescue staff reached out and expanded the team to include agencies that were better suited to address social issues affecting older adults. The two primary agencies were the Department of Social Services (DSS), Adult Services Division, and the Joint Area Board of Aging (JABA), Options Counseling.

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Policy&Practice February 2018

and social services staff, Gertrude is now receiving much needed care to improve her quality of life. Creation of HUMAINS Based on the success of Gertrude’s case, combined with the need to address the high use of 911 services for nonemergency services among older adults, the task force formed the HUMAINS project—High Usage Customer Resource Network. The group’s charter is: “.. to work collaboratively to provide resources to individuals that are frequent utilizers of the EMS system and have needs that cannot be met by the current system. This would include in home care, in home equipment or mate- rials as well as external resources. Using all community resources available to aid in the betterment of the individual’s quality of life and personal safety.” The resources exist and oftenneed only connectivity to thrive. the genuine needs of customers ina community has resulted inamore integrated service deliverymodel. The genesis of such programs is rooted in ourwillingness to empower employees to seek atypical solutions to common challenges. This approach to holistically examining

The HUMAINS group has expanded the team to include mental health resources and home health care. The group’s caseload has expanded signifi- cantly, beyond its ability to address all needs. Long term, the strategy is to establish a sustainable program with full-time staff to help coordinate the efforts. In the meantime, Gertrude and other Albemarle County older adults are benefiting from a group of dedi- cated staff focused on helping their community. Vulnerable citizens who do not possess the ability or desire to seek added resources for their impedi- ments are afforded the assistance of knowledgeable agencies genuinely dedicated to helping. The HUMAINS project is an out- standing example of first responders projecting far beyond their typical service delivery model. The fire fighters, while willing to answer Gertrude’s many calls for service, recognized that this defenseless little lady’s needs exceeded their ability to truly solve her essential chal- lenges. This approach to holistically examining the genuine needs of cus- tomers in a community has resulted in a more integrated service delivery model. It also frees the fire fighters to respond to more pressing emergen- cies. The genesis of such programs is rooted in our willingness to empower employees to seek atypical solutions to common challenges. The resources exist and often need only connectivity to thrive. The next time your agency identifies a need or challenge, take a look at the resources that already exist. Develop relationships with other agencies and determine if there is an opportunity to combine and create a force multiplier for problem solving. The future of service delivery is not likely to hinge on creating something new, rather on investigating the extant systems and thinking beyond your current vision. Dan Eggleston is the Chief of the Albemarle County (VA) Department of Fire Rescue. Trish Suszynski is the Adult Services Supervisor with Albemarle County Department of Social Services.

In Virginia, self-neglect is consid- ered a form of adult abuse and is the most prevalent. Often the lack of social capital leads to isolation among older citizens. As a result, many individuals are reaching out to public agencies to fill in the gaps where natural support systems (social capital) such as rela- tives, faith-based organizations, and neighbors could ideally meet their needs. As with many social problems, sustainable solutions require an ecological and strengths-based per- spective. Outside of a family system, public service programs should be encouraged to collaborate and develop innovative solutions to meet the needs of their communities. One of Gertrude’s significant chal- lenges is that her closest family member, a brother, lived on the West Coast and they did not have a good relationship. She did not have local friends and rarely interacted with neighbors. Gertrude suffered from social isolation and did not generally trust anyone, especially officials that represent government or affiliated agencies. Gertrude refused to follow up with DSS or JABA for assistance and would always default to calling “her boys” when she needed care. The task force realized that the trusting rela- tionship between Gertrude and the fire fighters could be used to help bridge a relationship with other agency staff. Therefore, the fire fighters would take on the role as the patient’s advocate and slowly, but deliberately introduce DSS and JABA staff as their “trusted friends.” Results The process of putting the fire fighters in a role as the trusted friend proved to be very effective. The fire fighters spent generous time intro- ducing Gertrude to the social workers and options counselors and often stayed during the initial assessment to help address questions and concerns. It turns out that Gertrude had sig- nificant health challenges, including undiagnosed mental health issues that exacerbated her declining living condi- tions. There was no doubt that gone unchecked, Gertrude would have con- tinued on a downward spiral. Thanks to a group of dedicated public safety

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February 2018   Policy&Practice

The Health and Human Services Workforce PART 1

his article kicks off a special 2018 APHSA member initiative celebrating the health and human services (H/HS) workforce. Through a year-long effort called Igniting the Potential we intend to showcase the many contributions of the workforce in unlocking and igniting the potential of all people in our communi- ties. We will shine a spotlight on member agencies applying innovative approaches in supporting the professional development of their workforce and will contribute additional tools and guidance agency leaders can use. We will also work with our partners to highlight ways in which we can all ensure that the very people who carry out the day-to-day work of human services are themselves healthy and well.

By Tracy Wareing Evans

need for systemic change. As we have captured in our Human Services Value Curve Toolkit (see the Resources page at www.aphsa.org ): Leaders must anticipate and respond to resistance to the changes that are a part of [any] transformation, both enlisting the support of constructive resisters and marginalizing those who resist for non- constructive reasons. The development of a sound communication plan helps leaders message the changes in a clear and concise way. These messages should include the rationale for the changes and address the benefits to the organization, staff, and stakeholders. Painting a clear picture of the expected outcome of the transformation effort is essential. As the transformation progresses, leaders must authorize the organization to bring an end to the “old ways” and exchange them with new policies, processes, and prac- tices that will support the new way of doing business. To expect our workforce to innovate and help solve problems, we have to set them up for success. To do so, leaders must first hire for adapt- ability and agility to work within and across the complex human-serving systems. We must also create a zone of safety and support, where there is shared ownership to take risks through a “learn-by-doing” approach. Supporting the workforce also requires that leaders create the time and space for managers to reflect on whether they are focusing the workforce on the “right” tasks and interventions; we must be willing to intentionally “unpack” what it is we do to determine its true value and impact. A great example of this wholesale shift in culture and climate is Jefferson County, CO, where the turnover rate has been reduced frommore than 30 percent to 11 percent in a just a few short years. Inspired by the Olympic coaches who train athletes in their backyard, Jefferson County leadership asked a simple question, “How do we get gold for each family in our community?” Through the lens of the Value Curve and in true partnership with families, the agency created a different mindset by positioning its workforce as goal setters and problem solvers, not “case

In our 2017 member survey, concerns about the agency workforce topped the list of what keeps H/HS leaders up at night: the ability to recruit and retain staff with the right talents and capabilities; how best to develop and train the workforce in a fast-paced, ever-changing world; how to equip them with the right tools; how to ensure the on-going well-being of front-line staff and managers. Building on the field’s shared learning through the Human Services Value Curve and using APHSA’s strategic plat- forms, including our three Collaborative Centers, affinity groups, Organizational Effectiveness practice, educational events, and communication vehicles— our aim in 2018 is to further support the field in developing a modern workforce that is healthy and well. The workforce sits at the core of how human services agencies deliver on their missions. Absent a talented, well-equipped workforce, it’s nearly impossible to drive the outcomes we desire for communities. We must align internal agency practices with modern policies through a systems-level lens if we are to ensure the success of the workforce and, ultimately, realize the full potential of people and places. When we see and engage the human services workforce as helping “unlock and ignite human potential,” we both energize and honor our workforce and we create an important mindset shift about their role in partnership with families and communities. When we can create an authentic sense of con- nectedness between the workforce and the community, we can solve problems together. We know, however, that human services agencies have deeply embedded cultures that too often run counter to the highly agile and adaptive nature of today’s world. Agency climates can be subject to pendulum swings based on leadership changes, budget constraints, negative media coverage, and ever-changing laws and regulations, among other variables. We also know that the solu- tions of the past are rarely the answers to today’s challenges. Hence, tackling cultural change requires that agency leaders act inten- tionally, repeatedly emphasizing the

Igniting the Potential will be a recurring theme for 2018. In each article, we will introduce our readers to various efforts underway in the H/HS workforce. If your organization has a compel- ling 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

TracyWareing Evans is the President and CEO of the American Public Human Services Association.

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Policy&Practice February 2018

The Human Services Value Curve

Ef ciency in Achieving Outcomes

Finally, in partnership with Dr. Beth Cohen, a licensed clinical and organi- zational psychologist who has devoted much of her career to supporting public-sector agencies, we will explore what it takes to ensure the health and well-being of the workforce, and how to measure it. Informed by empirical data in the field, our goal is to design a blueprint of a comprehensive organiza- tional model focused on individual and organizational workforce health and well-being. In much the same way, we have begun to better understand how to more authentically and effectively engage with families. We must consider how to tap the strengths of our work- force and understand what motivates and drives them as well as what causes unproductive stress. Consider this: Do we ever ask our own staff what their dreams are? How about what impact they aspire to leave on the world or for their own families? Do we know what overwhelms them or do we simply make assumptions about their stresses without understanding themmore Regulative Business Model: The focus is on serving constituents who are eligible for particular services while complying with categorical policy and program regulations. Collaborative Business Model: The focus is on supporting constituents in receiving all services for which they’re eligible by working across agency and programmatic borders. Integrative Business Model: The focus is on addressing the root causes of client needs and problems by coordinating and integrating services at an optimum level. Generative Business Model: The focus is on generating healthy communities by co-creating solutions for multi-dimensional family and socioeconomic challenges and opportunities.

Generative Business Model

Integrative Business Model

Collaborative Business Model

Outcome Frontiers

Regulative Business Model

Effectiveness in Achieving Outcomes

© The Human Services Value Curve by Antonio M. Oftelie & Leadership for a Networked World is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Based on a work at lnwprogram.org/hsvc. Permissions beyond the scope of this license may be available at lnwprogram.org.

managers.” They began to “hire for the heart and train for the brain.” And, by requiring all staff to read books like JimCollins’s Good to Great, they have developed a shared language and strong peer community—not only energized by each other to solve problems together— but also help check each other’s thinking when a teammember is not operating within their “passion circle.” This is just one example of agency leadership making it possible for an entire workforce to think innovatively by tapping their internal motivations, con- necting hearts andminds, moving from program-focused practices to cause- driven services, and enabling leadership at all levels. Over the course of the next year, we will showcase many more examples of such efforts, including: � Leadership academies that develop champions across the agency � Innovative approaches in performance management and moti- vational coaching � Applied learning from neuro- and behavioral science in developing the capacity of the workforce � Mindfulness and other meditation activities to support wellness

� Collective impact efforts from the ground up that are demonstrating how to meet families where they are and connect As part of the Igniting the Potential initiative, we will also highlight how data-driven and evidence-informed practices present new opportunities for leaders to increase their agency’s impact while reducing inefficiency. As leaders shift resources to data- driven approaches, they must ensure that the workforce is a critical part of that shift, avoiding the temptation to act in a top-down manner. Leaders must ensure that the workforce first sees data as an enterprise asset, and then has the tools to use the data to drive both individual-level and community-wide decisions. The work of our National Collaborative for the Integration of Health and Human Services already has a number of tools to support data integration and use (see the National Collaborative page at www.aphsa.org ); and we will continue to develop guidance to support effective use of data by the workforce.

See Igniting the Potential on page 33

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February 2018 Policy&Practice

daptive leadership skills are crucial in human services agencies, many of which are still grappling with the tremendous capacity issues A D A P T I V E L E A D E R S H I P Streamlining Processes Before Automation By Leo Ribas A

brought on by workload increases surrounding the crumbling of the national economy nearly a decade ago and the implementation of the Affordable Care Act (ACA). Despite significant investments in technology that promised to solve these workload challenges, our cus- tomers are still waiting 20 to 30 days for the decisions they so desperately need. Our technology innovations helped us organize those 20 days of unfinished work, but they have yet to help us eliminate it. Automation of existing practices seemed like the best way to respond to these challenges, when in reality, the answer was much simpler: We must first evaluate and redesign our service delivery pipeline—the method through which the work of reaching an eligibility determination is actually completed—to address our capacity challenges, and then we can utilize technology to automate the strategies we have put in place. The redesign and reinvention of how we work is very different from how we automate our work. There is always a role for technology, but automation is not innovation. Redesign efforts bear more fruit and allow agencies to better utilize automation than hoping the automa- tion alone will produce radical results. A truly adaptive leader embraces this nontraditional thinking to develop innovative solutions that yield real, lasting improvement.

Thirty Minutes of Work If you are one of the many human services agencies that chose to rely solely on automation and technology in the face of mounting caseloads and the advent of the ACA, you might be asking yourself, “Isn’t the whole point of these new IT systems not to have to redesign how our work gets done?” This is the largest, most expensive misconception in government—that new eligibility systems will handle the increased demand for services and make work time more efficient. New technology solutions play a role in assisting with the automation of our work and making reporting and data collection easier, but they do not, on their own, make significant strides in helping states increase capacity and serve more customers. Technology automates our work, but the work is not where we struggle. To complete an eligibility determina- tion, staff requires about 30 to 60 minutes of work time, yet it takes several weeks for customers to receive a final determination. The total time from first interaction to determina- tion is what we call elapsed time. The gap between that elapsed time and the time when the work is occurring is between 95 percent and 99 percent; that is where the opportunity really lies. Automation tends to focus only on the work time, which is such a small percentage that even a 50 percent improvement in work time only affects 5 percent of the total elapsed time, for an efficiency savings of only 2.5 percent overall. Because we lose the majority of our time in the gap, a process redesign must focus on why we struggle to find the time to do the 30 minutes of work.

current caseload. When you analyze the issue carefully, you’ll find there are two primary issues draining capacity: 1. Multiple interactions with the same customer that, in many cases, are unnecessary. In the states we have worked with, the average customer typically came into contact with the state or county agency, in-person or virtually, three to five times from the time of application to eligibility determi- nation. The longer a case remains in pending status, the greater the opportunity for customers to get in touch with staff. 2. Inconsistencies in business prac- tices and how the work is done. Our eligibility workers interview, verify, and document cases differ- ently. These inconsistencies create more work because no one can finish someone else’s case actions without re-starting the entire process. If the number one issue draining capacity is unnecessary multiple customer interactions, let’s resist the temptation to track and organize them through automation. Instead, just eliminate the number of contacts. The only way to truly do this is by applying what we call a First Contact Resolution approach to every customer interaction—in person, over the phone, or by simply processing a piece of paper. The goal of a First Contact Resolution approach is to do every- thing within our control to complete the eligibility determination when first interacting with the customer or the case (within policy constraints that vary from state to state). This means not scheduling appointments, not relying only on the customer to gather verification (electronic resources, employers, etc.), by applying policy consistently, and avoiding “stacking and tracking” and to get everything you need from customers before they hang up or walk away. Initially, your overloaded workers will resist the concept of First Contact Resolution. It seems counter-intuitive to add time to the interview or deter- mination process. What they quickly realize, however, is that those 10 addi- tional minutes spent up front will save

The struggle for a faster determi- nation begins with the pressure to find the 30 to 60 minutes you need when the lobby, or call center, is full of customers all hoping to get help that day. To get through the line, offices do a smaller portion of the 30 minutes of work and the remaining work is shifted to a later date so they can get to the next customer. This “pend” work now requires additional work to track, manage, and eventu- ally complete. Many IT solutions focus on making this extra work easier by allowing sophisticated “pend” queues, the electronic transfer of applications, customer appointment scheduling solutions, and access to data needed to manage the pended applications and backlog. At best, these attempts help us manage the problem, but avoid addressing fundamental issues that originally caused the problem. The root cause of the problem is that the vast majority of customers are in the lobby, or calling in, because their applications are already in the pend queue and the customer is trying to move it along. Our data, gathered from redesigning the service delivery in more than a third of the states in the country, show that each pended customer requires between one and 2.5 hours of additional staff work time to come to a final determination and 10 to 15 days to the eligibility process (the total elapsed time). This additional “self-created” work robs staff of its capacity to do new work and forces even more pends. We have unintentionally created a perpetual cycle of work that will never allow us to catch up unless we change how we work. And while you might believe we don’t have the capacity to spend more time up front with customers to arrive at a determination, pending creates far more work in the long run. How bad is the problem? About 80 percent of the people calling in or waiting in the lobby for service are not new customers. Innovation vs. Automation: WhatTechnology Can’t Do forYouToday You are likely to agree that your biggest challenge is staff capacity or not having enough people to handle

Leo Ribas is a Partner at the Change and Innovation Agency.

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Policy&Practice February 2018

We recently worked with a state where 80 percent to 90 percent of all applications and renewals were pended. The team redesigning the process realized that each pending action added 10 to 14 days to the eligibility process and nearly two hours of work time for future inter- actions. Once they understood this simple fact, the idea of First Contact Resolution was a welcome relief.

up the phone and ask the customer the same basic eligibility questions. Consistent eligibility tools encourage people to do the eligibility work itself in a more standardized manner. For example, interview scripts identify the specific questions everyone should be asking when processing similar cases, a verification matrix ensures all workers use a consistent set of verifica- tion requirements, and a case narrative template ensures workers document in the same manner to eliminate the desire to re-interview the customer. Real-time tracking of operational metrics, meanwhile, allows you to assess inconsistencies in the model and address the root cause of the problem. All of these strategies are designed to foster consistency and eliminate rework to make more efficient eligi- bility determinations. Break the Perpetual Cycle: Two Simple Steps for the Adaptive Leader As an adaptive leader, you possess the perspective and vision to

them from handling more customer contacts—and the associated work that comes with it. We recently worked with a state where 80 percent to 90 percent of all applications and renewals were pended. The team rede- signing the process realized that each pending action added 10 to 14 days to the eligibility process and nearly two hours of work time for future inter- actions. Once they understood this simple fact, the idea of First Contact Resolution was a welcome relief. The second biggest issue draining staff capacity—inconsistencies in how we work—can easily be reduced through the development and consis- tent use of eligibility tools, measuring the right operational metrics in real time, and standard business practices. We define rework as any instance when one worker cannot finish someone else’s case without restarting the entire process. It could be that the first worker didn’t follow the correct process, failed to document the actions taken, or wrote so many case notes that the finisher found it easier to pick

understand that addressing the core problem within your agency—lack of capacity and its impact on service delivery—will be the best innova- tion you can bring to your customers and staff, whether or not you have already decided to pursue automation. The difference between redesigning your business processes and putting in place the IT solutions that focus on managing our problems is we can address the fundamental ways of how we work, break the perpetual cycle, and teach our workers how to serve more people through two simple steps: apply a First Contact Resolution approach and implement consistent eligibility tools and standard business practices. Our goal is not to monitor the pend queues better, but rather to reduce the number of pending cases by 80 percent. It is not better tracking pending work, but reducing the number of times we interact with customers. Our goal is not to manage the backlog, it is to get offices caught up and ensure they never get behind again.

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February 2018   Policy&Practice

QUESTION & ANSWER

CHAMPIONING

IN OUR FIELD PROGRESS

HOW

HUMAN SERVICES LEADERS

CAN ADVANCE

PAID FAMILY & MEDICAL LEAVE

BY KERRY DESJARDINS & GAYLE GOLDIN

As human services leaders, we con- stantly search for and test new and better ways of implementing human services programs and policies to attain better outcomes for our cus- tomers. We look for even the smallest components of the human services system with room for improvement, yet we tend to shy away from looking outside of the system to address issues that create barriers to the outcomes we want for our customers. Truly advancing along the Human Services Value Curve toward more integrative and generative models that examine root causes and co-create broader solutions requires us to extend our leadership and influence beyond the bounds of our human services universe. Paid family and medical leave is a prime example of a systemic change outside of the human services system that could dramatically impact the human services system and the customers we serve.

Years ago, as a new front-line human services worker, I remember being struck by the number of families I served who would have had no need to turn to public safety-net programs like Temporary Assistance for Needy Families (TANF) and food assistance if they had just had access to paid sick days, or paid family and medical leave. Though intended to promote parental employment, the TANF program has long served as a form of income support for low-income, single parents caring for infants. It allows parents to stay home with young children, thus benefitting child-well- being. However, it often requires them to detach from the workforce and depend on public benefits to meet their basic needs. This reality impacts the broader human services system by diverting resources meant to serve the program’s target population—parents who need assistance finding employ- ment. In fact, in a unique study in Wisconsin, analysis of TANF admin- istrative data from 2006 showed that a majority of TANF participants were exempt from work requirements; 48 percent were new mothers and 17 percent had a disability. 1 In other words, the majority of the state’s TANF participants were not parents who likely needed assistance finding employment, but rather individuals who might have been better served by a paid family and medical leave insurance program, or a temporary disability insurance program. Today, in my role at APHSA, I continue to hear from our members how lack of paid family and medical leave creates hardships for low-income families, causing them to turn to the human services system to meet their needs. Low-wage workers—whom we frequently serve through the human services system—are the least likely to have access to paid leave through their employer. 2 And in the few states that have statewide paid family and medical leave insurance, low-wage workers are the least likely to be aware of the program. Yet, there is ample evidence linking paid family and medical leave to the health and well- being outcomes we desire for them. Not only does access to and use of paid sick days and paid family and medical

KeyWins at the State Level

States with Paid Family and Medical Leave 2002 California

2008 New Jersey

2013 Rhode Island

2016 New York

Kerry Desjardins is a Policy Analyst at APHSA’s Center for Employment and Economic Well- Being.

2016 District of Columbia

Gayle Goldin is the Family and Medical Leave Insurance Campaign Advisor for Family Values @ Work.

2017 Washington

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leave promote health and well-being, mounting evidence also links it to employment stability and reduced dependence on public assistance. Women who take paid leave after a child’s birth report stronger labor force attachment and positive changes in wages in the year following a child’s birth, when compared to those who do not take any leave. When compared to women who return to work and take no leave at all following the birth of a child, women who return to work after paid leave have a 39 percent lower likelihood of receiving public assistance and a 40 percent lower likelihood of food stamp receipt in the year following the child’s birth. Likewise, men who return to work after paid leave have a significantly lower likelihood of receiving public assistance and food stamps in the year following the child’s birth, when compared to those who return to work and take no leave at all. 3 Paid sick days and paid family and medical leave benefit all working families, but especially the low- income working families we serve every day through the social safety net, who are less likely to have access to paid leave through their employers. As human services leaders, we can attest to the significant number of our customers who turn to the social safety net because they temporarily cannot work due to medical issues or caregiving responsibilities. The potential impact of family-friendly workplace policies like paid family and medical leave would have a beneficial impact on the human services system and on our customers by helping low-wage workers stay in the workforce. To learn more about this issue, and how human services leaders can lend our voices to the movement for family-friendly workplace policies and co-create solutions to one of the root causes of employment instability and economic hardship, I turned to Gayle Goldin, Family and Medical Leave Insurance (FMLI) Campaign Advisor for Family Values @Work (FV@W). KerryDesjardins: Gayle, can you briefly describe Family Values @Work and your organization’s work?

GayleGoldin: Family Values @ Work is a national network of 27 state and local coalitions helping spur the growing movement for family-friendly workplace policies such as paid sick days and family and medical leave insurance. Formed in 2003, Family Values @Work coalitions have led changes to paid sick days and family and medical leave insurance laws in municipalities and states across the country. Our coalitions represent a diverse, nonpartisan group of more than 2,000 grassroots organizations, ranging from restaurant owners to restaurant workers, faith leaders to public health professionals, think tanks to activists for children, seniors, and those with disabilities. GG: Currently 14 percent of U.S. workers have access to paid family leave and less than 40 percent have personal medical leave through an employer-provided disability program. According to a recent survey, nearly one in four pregnant women who are employed return to work within two weeks of giving birth largely because they cannot afford to go without pay. Yet, research shows investing in paid family leave is worth it. Access to paid family leave increases the likelihood of breast- feeding and regular checkups. It can also lead to shorter hospital stays, which improve health outcomes and decrease health costs. Studies show a decrease in infant mortality and low birthweights. Laws creating FMLI have passed in California; New Jersey; Rhode Island; New York; Washington, DC; and Washington State. California was the first state to pass paid family leave in 2002, and since then the momentum has been building. Now, more than a dozen states have introduced FMLI bills, and legislators in California, New Jersey, and Rhode Island have introduced bills to improve on their existing law. People who work in California, New Jersey, Rhode Island, and New York KD: What is the status of paid family and medical leave policy in our nation?

Paid Leave Intended Consequences

Breastfeeding STRENGTHENS

Vaccinations

Jobs/economic well-being

Families

Role of dads

Senior independence

Healing

Women’s workforce attachment

LOWERS

Maternal mortality

Infant mortality

Premature births

Inequality

Family instability

Get more info @ familyvaluesatwork.org/facts

See Paid Leave on page 32

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February 2018 Policy&Practice

THE POWER OF A GENERATIVE ECOSYSTEM

INSIGHTS FROM LEADERS AT THE 2017 HARVARD HHS SUMMIT

BY BARBRA MCGANN

“It takes a village to raise a child.”

A nd these days, it takes a network of villages—an ecosystem—to generate new levels of impact on people’s well-being. While tapping into the incredible resources of such an ecosystem is complex, digital technology and passionate people can make it happen. That’s the vision of the health and human services agencies in the United States. It’s about creating thriving families— healthy, educated, and safe—at the heart of ecosystems because a child thrives within the nucleus of family. An ecosystem in this context is a set of organizations, systems, and services networked to create better outcomes. Health and human services agencies exist to harness the capacity of the ecosystem to create and sustain these environments and to identify and solve the root causes that chal- lenge this vision. It’s a lofty goal, and one that inspires, challenges, and energizes an amazing group of public service leaders, as evidenced at the Health and Human Services Summit hosted by the Technology and Entrepreneurship Center (TECH) at Harvard University, developed by the Leadership for a Networked World in collaboration with Accenture and the American Public Human Services Association (APHSA). Agencies that can collaborate and show impact on outcomes such as decreasing heart disease and child- hood obesity (e.g., San Diego, CA), curtailing the opioid epidemic (e.g., Kentucky), or reducing neighborhood

Successful H/HS Agencies Create Ecosystems that Enable Families to Thrive When it’s good it’s really, really, good… In one example, the members of a health and human services (H/ HS) ecosystem came together to support a family in trouble. Four kids and a mom from a violent relation- ship, who were homeless, became the nucleus of an effective ecosystem that included the legal system, human services, transportation, and educa- tion—entities all working with the family. They polled, communicated, and supported each other to keep track of and support the kids and parent. These kids are now a dis- tinguished academic, an artist, an accountant, and a U.S. Army officer. … and when it’s bad, it’s horrid… In a separate and unfortunate situa- tion, U.S. marshals visiting a house with an eviction notice found four kids who had died. Their mother had been on food assistance, rental assistance, and in a program for mental health issues, and the kids had been receiving transportation aid to get to and from school. All of these are public services, and yet no single element of the system had raised an issue or alert or (evi- dently) communicated with the others when the students didn’t show up at school or the mother didn’t show up for a mental health appointment. It’s a truly sad and unfortunate case of a broken system. These stories each serve to show the criticality of working across organi- zational silos and bringing together services, technology, and people that focus on educated, healthy, and safe families. In the second example, the system was broken—likely organi- zations were working in silos and according to their own processes. In the first example, each of the organiza- tions put the family first, and it drove their interactions and communications because they all shared that focus. It led to better outcomes. As one of the agency leaders at the summit sum- marized, “Don’t look at the network internally… look outward at the customer… and focus externally.”

crime through local efforts in Mecklenburg County, NC, earn

legitimacy—the right to operate in a democratic society. Just as private com- panies are beholden to customers and shareholders, public agencies are tied to their constituents. Therefore, the organization, ecosystem, and services of health and human services agencies need to be centralized and focused on the family. That’s the motivation that brings agency leaders together at the summit to share what’s working and explore how to keep evolving to break down barriers within and between organizations and the public they serve to create effective ecosystems. At last year’s summit, 92 percent of the attendees said that building new ecosystems is critical to create change because of all the touch points with individuals in communities and the limited resources they have to engage. 1 This year, more than 70 percent of the agency leaders in attendance said they anticipate a significant or extreme increase in the expectations to deliver better outcomes, and that ecosystems play a critical role. During the two-day summit, leaders from health and human services agencies in the United States and Canada explored what makes an effec- tive ecosystem—who (people) and what (data and systems) need to be in it, how to use it to achieve better results, examples of work underway, and what organizations are learning. What is really happening in assembled teams to create the future? What does the future of outcomes look like and how do we create it? How do you get more impact from constrained capacity? Because—bottom line—the public wants not just to know but feel the value generated by its govern- ment, which depends on how health and human services agencies create collaborative ecosystems to harness, focus, and increase capacity to deliver better outcomes. That means, as Paul Fleissner, Director, Olmsted County Community Services, summarized: “We need to focus on the person, and they don’t come in pieces the way we are often organized to serve.”

Barbra McGann is an industry analyst, corporate strate- gist, and writer. Reprinted courtesy of HfS Research.

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