Policy & Practice | Spring 2026

The Magazine of the American Public Human Services

Association Spring 2026

shaping the future of human services

Join us as we dive into this yea s five t ac s shaping some of the most timely conve sations in human se vices. Improving SNAP Payment Accuracy, Quality Control, and Program Integrity Implementing SNAP Work Requirements and Employment Supports Strengthening Families and Communities Through TANF and Human Services Modernizing Benefits Delivery to Expand Access and Improve Outcomes Advancing Innovation, Waivers, and Program Design | AUGUST 23-26 2026 NEW ORLEANS LA ECONOMIC MOBILITY & WELL BEING CONFERENCE

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contents

Vol. 84, No. 1 Spring 2026

features

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Closing the Gaps in Counties How Social Care Integration Technology Relieves Systems and Improves Community Services

Practical Solutions for Child Welfare 5 Ways States Can Ensure Every Child Has a Home

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Shifting the Focus How Proactive Accuracy in Eligibility Determination Is Shaping the Future of Human Services

The Future of Medicaid Advancing Eligibility Through a Marketplace Model

departments

4 From Our Partners

8 Summit Sneak Peek

28 Staff Spotlight

Reducing Churn in 2027: Communicating Upcoming Medicaid Community Engagement Requirements

Honoring Older Americans: Strengthening Systems, Health, and Community Impact

Nicole Acosta, Process Innovation Coordinator

6 Summit Sneak Peek

26 Technology Speaks

The Future We Build Together: What Writing a Book Taught Me About Human Services Leadership

How a Community-Led Approach to Digital Services Can Engage and Empower Citizens

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Spring 2026 Policy & Practice

APHSA Executive Governing Board

Strategic Industry Partners DIAMOND

Elected Director Christine Norbut Beyer, Executive in Residence, Think Of Us Elected Director Charlie Brereton , Director, Montana Department of Public Health and Human Services Elected Director Vannessa L. Dorantes, Managing Director, Casey Family Programs Elected Director Tracy Gruber , Executive Director, Utah Department of Health and Human Services Elected Director Eboni Washington , Director of Government and Community Relations, Action for Child Protection Immediate Past Chair Dannette R. Smith, Former Commissioner, Colorado Behavioral Health Administration and Former CEO, Nebraska Department of Health and Human Services President & CEO Reggie Bicha, President & CEO, APHSA

Chair Grace Hou, Deputy Governor for Health and Human Services, State of Illinois Vice Chair Kristi Putnam, Executive Policy Advisor Treasurer Sherron Rogers , Vice President, Finance, Children’s Hospital of Philadelphia Affinity Group Representative Karen Barber, General Counsel, Vermont Department of Mental Health Leadership Council Representative Jeffrey Cartmell, Executive Director, Oklahoma Human Services Local Council Representative Dan Makelky, Director, Arapahoe County (CO) Department of Human Services Elected Director Rodney Adams, Principal, R Adams & Associates Elected Director Derrik Anderson, Executive Director, Race Matters for Juvenile Justice

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Policy & Practice Spring 2026

Policy & Practice™ (ISSN 1942-6828) is published four times a year by the American Public Human Services Association, 901 North Glebe Road, Suite 210, Arlington, VA 22203. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2026. 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 901 North Glebe Road, Suite 210, Arlington, VA 22203

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President & CEO Reggie Bicha Communications Director Jessica Garon jgaron@aphsa.org

Editor Amy Plotnick

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Spring 2026 Policy & Practice

from our partners

By Jeff Burke, Kate Holman, Betsy Park, and Tiffany Dovey Fishman

Reducing Churn in 2027: Communicating Upcoming Medicaid Community Engagement Requirements

S tarting in January 2027, Medicaid requirements will change for an estimated 20 million beneficia ries. Clear guidance and effective outreach from states can help confirm that eligible beneficiaries do not lose coverage due to missed steps. Under H.R. 1, signed into law in 2025, Medicaid expansion ben eficiaries (Medicaid recipients ages 19–64, up to 138 percent of the federal poverty level, not categori cally eligible) may need to complete at least 80 hours per month of com munity engagement (work, school, training, or volunteering) to maintain their coverage. Certain groups may be exempt (e.g., those with quali fying health conditions, those who are pregnant or postpartum, or those outside the age range). States must implement these provi sions and notify potentially impacted residents. The communications imper ative is straightforward: translate policy changes into clear, actionable steps to reduce potential confu sion or lose coverage due to missed requirements. As time is limited, outreach should be simple, repeated, and delivered across the channels beneficiaries already use.

help identify beneficiaries at higher risk of noncompliance and support persona-based messaging tied to specific actions. Geospatial insights can further focus outreach on priority neighborhoods and connect benefi ciaries to nearby resources (e.g., job centers, nonprofits, events) for in person support. Map the beneficiary journey: Once audiences have been identified, the beneficiary journey for each segment should be mapped, from first hearing about changing Medicaid require ments to ultimately participating in activities to maintain coverage. This helps identify what messages to send at pivotal points in the journey to help beneficiaries navigate challenges such as difficulty finding approved activities or reducing confusion about how to log hours to maintain compliance.

this is a risk-mitigation and cost-sav ings lever for states: timely reminders reduce missed renewals and prevent churn, which can drive administrative rework, increased service demand, and costly re-enrollment. For Medicaid, the cost of a single person “churning” can be as high as $600. 2 An effective omni-channel campaign includes four building blocks: segmenting audiences, mapping the beneficiary journey, reaching people in the moments that matter, and continuously improving performance based on results. Segment audiences: Begin with a clear view of the target audience— their needs, motivations, and barriers. Population insights can then be used to segment beneficiaries and tailor channels and messages to each segment. Demographic, social, economic, and health signals can

Omni-Channel Campaign Approach

Consumers often require multiple touchpoints before taking action, so repeated, consistent outreach across a variety of channels they already use can help to move beneficiaries through onboarding, application milestones, and renewals. 1 Beyond engagement,

Illustration by Chris Campbell

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Policy & Practice Spring 2026

Reaching Beneficiaries Where They Are States can use a mix of channels to deliver timely, accessible information and prompts across key touchpoints tailored to different audience segments.

Reach beneficiaries in the moments that matter: Channels should be selected to reach each segment aligned with their journey, prioritizing where beneficiaries already spend time and reinforcing consistent messages across multiple touchpoints to build recognition, trust, and prompt beneficiaries to take specific actions during these moments that matter. Using existing beneficiary data (mailing address, email address, mobile phone number), states can personalize direct mail, email, and SMS campaigns and tailor messaging to each beneficiary’s journey (e.g., their Medicaid renewal cycle), include guidance to log continuous eligibility hours for compliance, and feature personalized elements such as the beneficiary’s name and clear next steps (e.g., “Find community engagement [CE],” “Submit renewal”) to boost credibility and prompt action. To speed deployment, campaign teams can use a library of creative assets to efficiently customize and launch ads targeting different segments. This includes using simple language with direct calls to action and imagery that reflects the beneficiaries the campaign intends to reach. Enhance campaign success: Campaign performance should be monitored and enhanced using delivery, open, click-through, and renewal completion metrics. These results inform practical adjustments— shifting spend to higher-performing creatives, refining copy and calls to action, and reallocating effort to the channels that drive response—helping states efficiently and effectively utilize limited outreach dollars. By combining direct outreach, digital and traditional media, and in-person assistance, the campaign meets beneficiaries in the channels and settings that work effectively for them and in the moments that matter most. Frequent, targeted messaging keeps beneficiaries informed and engaged, while direct communication and community-based support help answer questions and reduce barriers such as limited digital literacy or internet access. Together, these touch points improve understanding, drive

Email and SMS: Roughly 74 percent of Americans prefer receiving information via email and 56 percent via text. 3

Paid search: Paid search can capture active intent because 85 percent of U.S. residents use Google when searching online, making targeted terms like “CE requirements” and “Medicaid changes” a practical way to share guidance. 4

Digital channels: With mobile and internet access now widespread, digital channels can be an efficient way to effectively engage beneficiaries and reinforce direct outreach tactics. Social media remains a high frequency reach lever, with about 71 percent using Facebook, 50 percent using Instagram, and 37 percent checking social platforms multiple times per day. 5 Digital paid media channels such as social media (e.g., Instagram, Facebook), over-the-top (e.g., Hulu, Netflix), and programmatic display (e.g., banner ads on websites) facilitate deployment, testing, and refining ads based on real-time feedback to help states effectively use marketing dollars and keep messaging relevant.

Traditional media: Traditional media channels such as TV and radio ads, and out-of-home ads (e.g., transit ads, billboards) can help states reach less digitally savvy audiences or extend the reach of the campaign into rural areas with limited broadband access.

Trusted partner channels: To complement direct marketing and paid media, states can collaborate with managed care organizations and community based organizations (e.g., local YMCA, health office at a higher education institution, local food bank) to increase credibility and provide in-person help. Partners can be equipped with informational toolkits and varied support (e.g., informational webinars to answer questions) so they can help beneficiaries gather documents and navigate next steps. As part of the outreach strategy, states can also collaborate with local organizations to host community events with enrollment help desks and physical handouts. In-person touchpoints like these can reduce access barriers (e.g., digital fluency, internet access) identified during initial population analysis.

timely action on critical updates, and build trust by providing help when and

she watches a short explainer and realizes she needs a plan to meet CE requirements. The next week she searches “Medicaid changes” and returns via paid search. The page points her to a local community-based organization for job support; she gets help, secures a 20-hour/week job, and the state verifies wages automatically through payroll matching. Her portal updates to “Work requirement verified, no action needed,” and renewal continues without manual hour reporting.

where it is needed. Omni-Channel Campaign in Action

The following example shows how aligned messages across channels move a beneficiary from awareness to verified compliance. Maria (age 32) works part-time and prefers communications in Spanish. She sees a social media ad about 2027 CE changes, clicks to the state landing page, and leaves. Two days later, an SMS reminder brings her back;

See Reducing Churn on page 28

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Spring 2026 Policy & Practice

summit sneak peek

By Tracy Evans

The Future We Build Together: What Writing a Book Taught Me About Human Services Leadership

W hen I stepped down from leading the American Public Human Services Association (APHSA) at the end of 2023, I expected a shift in pace. I did not expect such a profound shift in perspective. For 13 years, I worked shoulder to shoulder with state, local, and com munity-based human services leaders nationwide. Together, we navigated economic upheaval, public health emergencies, natural disasters, federal shutdowns, and deep political division. We weren’t simply responding; we were advancing modernization, strengthening cross-sector alignment, elevating the workforce, and pushing for more integrated, responsive, and human-centered systems. At the time, much of that progress felt incremental—one policy shift, program redesign, and new partnership at a time. Writing American Welfare: Reclaiming the Dream for All of U.S. gave me the distance to see it differently. What felt like routine leadership was, in fact, the steady construction of a more resilient foundation. That progress continues today. The future of human services depends on leaders who understand both its tech nical complexity and its civic purpose. I am grateful and encouraged to see that work carried forward at APHSA and beyond, with clarity and resolve. When I began writing American Welfare , I thought I was examining history, especially how the word “welfare” became distorted, how stories of blame and scarcity hardened into policy, and how those policies shaped public perception. But as the manuscript took shape, I realized

something unexpected: This book is as much about the future we are building together as it is about the past. Writing helped me connect threads I had witnessed firsthand: local inno vations, quiet redesigns, the push to make front doors more welcoming and eligibility more seamless, and the insistence—often in rooms where it wasn’t fashionable—that public systems must reflect fairness, reli ability, and belonging. Human services are not peripheral to democracy. They are infrastructure— the quiet architecture that determines whether families can withstand dis ruption, whether children have a stable footing, whether older adults age with support, and whether trust in govern ment grows or erodes. And infrastructure does not build itself. What I Learned About Narrative One of the deepest lessons of the writing process was about story. Over the years, we have focused on modern ization, alignment, integration, and performance. Writing a book forced me to confront a harder question: What stories are shaping these systems? Many of our structures were built in eras defined by suspicion with assumptions about worthiness and scarcity. Those narratives shaped forms, verification rules, funding silos, public messaging, and, ultimately, how people experience human services. Yet what I routinely witnessed in your leadership was a quiet but persis tent reframing.

n You spoke of customers as neighbors. n You elevated the human services workforce as builders of possibility. n You understood that policy design is also narrative design. When you redesign systems, you rewrite the story beneath them. I saw it in counties that shifted language, in states that brought families to the table, and in agencies that embraced cross-sector collaboration because families do not live in silos. The future of human services will not be built on technical upgrades alone. It will require narrative courage—the willingness to replace outdated assumptions with a more expansive story of shared well-being. Belonging is sometimes dismissed as aspirational. In practice, it is concrete: Is the benefits application understand able? Does the eligibility determination account for context and complexity? Are community partners trusted co designers? Does the first interaction feel welcoming or scrutinizing? Belonging is built—or denied— through design. Across the country, I have seen leaders who know that if we are not intentional, belonging defaults to exclusion. They are rethinking procure ment, data sharing, and performance measures not as neutral decisions but as signals about who counts. What I Learned About Belonging Another thread in the book is belonging.

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Writing gave me distance. Distance gave me clarity. And clarity deepened my appreciation for the scale of what you do every day. The future of human services will not be shaped solely by federal legisla tion or new platforms. It will be shaped by leaders willing to see systems as design choices, not inevitabilities. WhyThis Moment Matters The focus on the future in this issue of Policy & Practice could not be timelier. We stand at a crossroads. We can continue treating human services as residual safety nets, or we can recognize them as foundational infra structure—essential to economic resilience, community stability, and democratic trust. The work ahead requires three commitments: n To tell a fuller story about what human services are and why they matter. n To design with the people most affected, not merely for them.

That shift from managing programs to designing systems that foster belonging may be one of the most important frontiers in our work, and it is already well underway.

n To measure success not only by com pliance or caseloads but by whether people are faring well. “Faring well” reminds us of the original meaning of welfare. It invites us to measure democracy by the steadi ness of people’s footing—and by the well-being of all of us. As I prepare to join you at the APHSA National Human Services Summit , I come as a collaborative partner shaped by your example. American Welfare carries insights forged through con versations, site visits, conferences, hallway debates, and shared problem solving across this network. You inspired it. And the future of human services—the future of democracy’s infrastructure—will be built by you. I am grateful to continue standing with you in that work.

What I Learned About Resolve We are in an era defined by

economic volatility, technological acceleration, demographic change, climate instability, polarization, and erosion of trust. In the book, I describe these as pres sures testing democracy’s scaffolding. If that scaffolding is under strain, it is because the work of strengthening it has been chronically underrecognized. Human services leaders operate at the hinge point between national policy and lived experience. You are asked to innovate without stable funding, integrate systems built for fragmentation, communicate clearly amid misinformation, hold compassion and accountability, and stretch dollars while expanding possibility.

Tracy Evans is the Founder and Principal of Cornerstone Solutions.

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Spring 2026 Policy & Practice

summit sneak peek

By Natalie Zarrillo, Jessica Johnston, Natalie Williams, and Karen Walker

Honoring Older Americans: Strengthening Systems, Health, and Community Impact

E ach May, Older Americans Month recognizes the contributions of older adults and underscores the importance of supporting healthy, connected, and dignified aging. Older adults are essential contributors to thriving communities and strong local economies, serving as caregivers, vol unteers, mentors, workers, neighbors, and civic leaders whose knowledge, leadership, and lived experience strengthen communities across generations. A strengths-based view of aging rec ognizes that older adults are defined not by system interactions or chal lenges, but by resilience, adaptability, and lifelong contributions. Aging is a natural part of the life course, shaped by both individual experiences and the broader environments and systems that support them. Ensuring those contributions are sustained requires systems that protect financial security, support participation, and reduce barriers at every stage of life. Many challenges associated with aging reflect life-course patterns, including changes in health, income, family roles, and social connection that can emerge at any stage of life but often become more visible later in life. For too many older adults, these challenges are compounded by fragmented systems leading to missed benefits, delayed care, and unnec essary complexity in accessing the supports they need. When systems are fragmented, people often experience unnec essary barriers, delays, and unmet needs before receiving support. Strengthening upstream,

Across the country, local com munities are advancing innovative, person-centered approaches to better support older adults through more connected service systems. In New Jersey, the Union County Department of Human Services (UCDHS) is strengthening community-based supports through investments in data, technology, and service innova tion, including the development of a chatbot to help older adults more easily navigate and access essential services and community resources. Within UCDHS, the Union County Division on Aging leads efforts to

community-based approaches can help address challenges earlier through coordinated health, human services, nutrition, housing, transportation, and social support systems that are easier to navigate and more responsive to people’s goals and circumstances. Core programs such as Medicare, Medicaid, and the Supplemental Nutrition Assistance Program (SNAP) remain foundational to stability and well-being in older adulthood. Their impact is strengthened when better integrated with each other and with community-based support, reducing complexity and improving access.

Illustrations by Chris Campbell

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responsive and connected systems of support: Key areas of focus include: n Leadership and community capacity building across sectors n Advancing social and economic well being across the life course n Leveraging technology, data, and innovation to reduce barriers and improve access n Strengthening community lead ership, engagement, trust and lived-experience partnerships to co develop local solutions n Promoting safety, health, and well-being to support dignity, stability, and connection Together, these priorities support a shift from reactive systems to more proactive, inte grated, and person-centered approaches that help individuals and communities thrive. We hope this conversation con tinues beyond these pages. Join us at this year's APHSA National Human Services Summit for our session, “Bridging Human Services and Aging Networks: A Community-Centered Model for Benefits Access and Well-Being Across the Lifespan,” on June 15 from 4–5 p.m., as we explore how cross-sector partnerships can strengthen benefits access, reduce enrollment gaps, and build more community-centered pathways to well-being across the lifespan. Natalie Zarrillo is the Executive Director for the Union County Division on Aging at the New Jersey Department of Human Services. Jessica Johnston is the Senior Strategist of Economic Well-Being at the National Council on Aging (NCOA). Natalie Williams is the Vice President of Community and Social Impact at APHSA. Karen Walker is the Senior Strategic Community Engagement Manager at APHSA.

Association (APHSA) are working alongside state and local leaders, community-based organizations, and individuals with lived experience to strengthen connected, people-centered systems through APHSA’s Community and Social Impact approach. Together, NCOA and APHSA are helping advance shared learning, cross-sector collaboration, and com munity-driven strategies that support health, well-being, economic mobility, and social connection across the life course. This collaboration reflects a

support older adults through a compre hensive continuum of programs and initiatives that promote health, inde pendence, dignity, and quality of life. As one of New Jersey’s 21 designated Area Agencies on Aging, the Division serves as a central access point for older adults, caregivers, and commu nity partners, coordinating services such as nutrition programs, care man agement, transportation assistance, caregiver support, wellness activities, information and referral, and access to critical benefits. Through partnerships with municipalities, nonprofit orga nizations, health care providers, and community groups, the Division works to identify emerging needs, reduce barriers to access, and ensure older adults are connected to the resources they need to age safely and suc cessfully in their communities. Building on this work, the Union County Division on Aging—rec ognized as the first in the state to do so—has launched an AI (arti ficial intelligence) assistant, EVA, to enhance access to informa tion and support. EVA provides immediate, user-friendly assis tance through an interactive platform while also connecting individuals to Information and Assistance Specialists when more personalized guidance is needed, improving accessibility, efficiency, and timely service delivery. This effort reflects a growing recognition that technology can play an important role in reducing administrative burden, improving access to trusted information, and strengthening connections between residents, service providers, and the resources that support well-being, independence, and quality of life. By leveraging innovation in coordinated and human-centered ways, UCDHS is demonstrating how local communities can modernize systems to better meet the needs of older adults. At the national level, the National Council on Aging (NCOA) and the American Public Human Services

shared belief that sustainable com munity impact happens when systems, organizations, and communities work together to co-create solutions that center dignity, choice, opportunity, and access. Through this partnership, APHSA and NCOA are helping communi ties identify opportunities to reduce barriers, improve coordination across systems, and strengthen upstream approaches that better support older adults and people with disabilities nationwide. Emerging from this work are several shared areas of focus that can help communities build more

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Spring 2026 Policy & Practice

Closing the Gaps in Counties

By Krithika Sudeswaran, Ross Maughan, Eric Kane, and Maryam Ghariban Systems and Improves Community Services How Social Care Integration Technology Relieves

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cross counties implementing integrated service delivery approaches, families are experiencing measurably better health outcomes even as budgets tighten and administrative demands grow. Diabetic patients connected to food assistance see better glycemic control. Pregnant mothers linked to WIC (Supplemental Nutrition Program for Women, Infants, and Children) and home visiting programs experience healthier pregnancies. Individuals experiencing housing instability who receive coordinated support reduce their emergency department visits. These outcomes—reduced chronic disease complications, improved maternal health, and decreased health care costs—represent what communi ties have long needed but struggled to achieve through fragmented service delivery systems. The challenge has never been a lack of programs or services. Counties offer Medicaid, the Supplemental Nutrition Assistance Program (SNAP), housing assistance, mental health services, and connections to community orga nizations providing everything from food pantries to job training. The challenge has been coordination: ensuring that someone applying for food assistance also learns about health care enrollment, housing support, and diabetes management programs; tracking whether refer rals to community resources result in services being delivered; and understanding which combinations of interventions lead to lasting improve ments in health and stability. A

Behind every policy change and budget constraint are real people whose health depends on maintaining access to services.

programs, rapid adaptation when policies change, and sustained support that treats health, nutrition, housing, and economic stability as intercon nected aspects of well-being rather than separate bureaucratic categories. What Changed: Communities Are Seeing Better Outcomes In Monroe County, NY, Medicaid members with chronic conditions are achieving better health outcomes through coordinated interventions that address both medical care and social needs. These outcomes emerged from coordination across multiple systems. Medicaid enrollment data connect to social services platforms. Caseworkers can see engagement with mental health services, whether individuals are accessing food assistance, and whether barriers like transportation are preventing medical appointments. Community organizations providing housing support can communicate directly with health care teams. Information flows securely across organizations with consent, creating a unified approach to supporting well-being. This kind of integrated, consent driven information sharing is equally critical in more complex and sensitive situations where coordinated systems must balance comprehensive support with stringent privacy protections. For victims of domestic violence in Los Angeles County, coordinated service delivery has meant sustained access to mental health care, medical services, and economic support while

modifications to SNAP work require ments, have added administrative complexity precisely when county budgets face severe constraints. Caseworkers carry overwhelming caseloads. Eligibility workers process applications under strict timelines while navigating constantly evolving policy guidance. Community health coordinators struggle to track clients across disconnected systems that do not share information. A New York State Association of Counties policy paper (see https://www.nysac.org/ news/posts/2026-legislative-program ) warns that federal policy changes could shift billions in costs to states and counties, threaten essential health and human services—especially in struggling areas—force local gov ernments to raise property taxes or cut services, and overwhelm county agencies with increased demand as federal supports are reduced. Behind every policy change and budget constraint are real people whose health depends on main taining access to services. When SNAP regulations shifted, thousands of adults who had been receiving nutri tion assistance suddenly faced new verification requirements and documen tation demands—even as many were managing chronic health conditions that made consistent nutrition essential. The traditional response to increased administrative burden has been hiring additional staff, which proves impos sible when budgets are frozen or cut, or accepting degraded service quality, which undermines the health outcomes these programs exist to achieve. Neither option addresses what families need: seamless coordination across

The Collision: Growing Needs Meet Shrinking Resources

Local governments administering health and human services face an increasingly difficult equation. Recent federal policy changes, including

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platform. When a caseworker deter mines that someone qualifies for food assistance, the system identi fies relevant community services, enables closed-loop referrals with the person’s consent, and tracks whether they engage with nutrition counseling and local food resources. It creates visibility into whether refer rals are helping, if barriers still exist, and what additional support might improve outcomes. This connectivity transforms scat tered programs into coordinated care—particularly important for rural communities where distance between services creates barriers. The platform integrates with existing 211 help lines, community health centers, food banks, and local organizations that families often contact first when in crisis. For rural residents who may drive long distances to reach services, digital coordination allows them to access comprehensive support without multiple trips. The bi-directional nature of this connection matters enormously. Community organizations become pathways into comprehensive support without requiring county hiring. The food pantry volunteer helping a family can also help facilitate their SNAP application, knowing that person will be seamlessly connected back to county eligibility systems. Community health workers can coordinate with Medicaid caseworkers, creating unified case management that addresses medical appointments, medication access, nutrition support, and trans portation barriers together. For Monroe County’s partner ship with TogetherNow, a nonprofit social innovation organization sup porting Medicaid innovation, this infrastructure enabled what the 1115 Waiver intended: addressing social determinants of health by connecting clinical care to community-based interventions. IBM and TogetherNow are leveraging the Connect360 platform— branded locally as MyWayfinder—to enable coordinated service delivery under New York State’s 1115 Waiver. MyWayfinder is TogetherNow’s imple mentation of Connect360, tailored to the Finger Lakes Region’s provider

maintaining strict confidentiality essential for their safety. Survivors report feeling that the system protects rather than exposes them. These outcomes—sustained engagement with trauma-informed care, improved safety, and better long-term health— depend on information sharing between law enforcement, health care providers, and social services while maintaining privacy protections that traditional siloed systems either over restrict or inadvertently compromise. The pattern is consistent: when services coordinate around the person rather than requiring them to coordi nate services, health improves. When caseworkers can see the full picture of someone’s needs and engagement across systems, they can connect people to appropriate interventions. When referrals include follow-up on whether services were accessed, gaps in care can be addressed rather than overlooked. How Coordination Happens: The Infrastructure Behind Better Outcomes These improved outcomes require technical and social infrastructure that most counties have not yet estab lished: the ability to share information securely across organizations, track referrals through completion, update eligibility rules rapidly when policies change, and understand which combi nations of interventions lead to lasting improvements. IBM Connect360 is a configurable social care coordination platform that connects the systems health and human services agencies, com munity organizations, and health care providers already use—giving caseworkers, care coordinators, and community partners a shared view of each person’s needs, referrals, and services in one place. Rather than replacing existing systems, Connect360 acts as the connective layer between them, enabling closed loop referrals, consent-based data sharing, and outcome tracking across organizational boundaries. This technology works by con necting providers, community-based organizations, regional health infor mation exchanges, and state or county agencies around a person-centric

Krithika Sudeswaran is a Business Architect and Delivery Lead at IBM Consulting.

Ross Maughn is Chief Technology Officer for State, Location and Education US, at IBM Consulting.

Eric Kane is Associate Partner and Offering Lead for IBM Community Health at IBM Consulting.

Maryam Ghariban is an Associate Partner at IBM Consulting.

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caseworkers avoid or that require workarounds undermining data quality. What distinguishes outcomes focused approaches is attention to how work actually happens. The platform evolves through continuous feedback from caseworkers, community members, community health workers, 211 partners, and people receiving services. When users say a workflow adds unnecessary steps, it gets streamlined. When community health workers identify barriers to documen tation, interfaces are redesigned. When caseworkers find the system genuinely helpful rather than bur densome, they document referrals consistently. When documentation is consistent, agencies can identify which interventions work. When community partners find coordination easy rather than frustrating, they engage more fully in integrated care. Sustaining Impact: Long Term Outcomes Require Durable Solutions Pilot programs often demonstrate promising results that fade once funding ends or staff turnover occurs. Counties need approaches that sustain impact despite budget uncer tainty, policy changes, and personnel transitions. Configuration-based plat forms supporting integrated service delivery address these sustainability challenges. When new reporting requirements emerge, dashboards can be configured to capture needed metrics. When community partner ships expand, new organizations can be integrated without system over hauls. For the Los Angeles County Domestic Violence Project, this dura bility has enabled years of sustained support for survivors. Secure coordina tion between law enforcement, health care, and social services continues operating reliably despite staff changes and evolving regulations. Measuring What Matters: Understanding Which Interventions Improve Lives Perhaps the most profound shift that coordinated infrastructure enables is moving from measuring activities to measuring outcomes.

Traditional systems count applica tions processed and referrals made. Integrated approaches enable tracking completed referrals, sustained service engagement, and long-term health and social outcomes. This includes both qualitative and quantitative data supporting the idea that systems work better when they are integrated and person-centered. One standout metric is a nearly 70 percent referral comple tion rate across a network of more than 40 connected providers. Counties implementing social and technical infrastructure can better answer important questions: Are the services we provide improving residents’ well being? Are resources reaching those who need them most? What Becomes Possible: Centering People and Community Well-Being The vision emerging from communi ties achieving better outcomes despite resource constraints is about what becomes possible when health, nutri tion, housing, economic stability, and safety are treated as interconnected aspects of well-being rather than separate bureaucratic categories. Technology enables this coordina tion by handling the data integration, referral tracking, and policy compli ance that have historically consumed staff capacity—allowing workers to focus on understanding individual needs and connecting people to support. The path forward for com munities facing tighter budgets and growing needs lies not in doing less but in coordinating better—treating every interaction as an opportunity for com prehensive support and continuously improving based on what actually improves lives. Communities exploring integrated social care infrastructure often begin with a pilot focused on a specific population or workflow. Starting with a defined use case allows agencies to evaluate coordina tion, staff adoption, and reporting value before scaling. States, counties, health systems, and community col laboratives seeking to advance social care coordination or rural health trans formation are invited to contact IBM to learn more about program design and potential pilot approaches.

landscape and community needs. Once live, the pilot will make it easier for Medicaid members to be screened for social care needs, assess eligibility for reimbursable nutrition, transporta tion, housing, and care management services, and coordinate referrals through the Social Care Network for the Finger Lakes Region. Adapting When Policy Changes: Maintaining Outcomes Through Transitions Recent SNAP policy modifications presented a severe test for Monroe County. Federal changes to work requirements for able-bodied adults without dependents created imme diate confusion among residents, who flooded local Department of Social Services offices with calls asking whether new age thresholds and exemption criteria applied to them. The county responded with a digital self-service screener developed and deployed in less than 30 days. The tool asked simple questions about age, work activities, health status, and caregiving responsibilities and instantly provided personalized results. More than 2,000 screenings in the first 2.5 months demonstrated imme diate adoption. Sixty-five percent of individuals identified an exemption and received clear next steps to notify the agency and avoid losing benefits. Another 6 percent learned they were subject to work rules and were con nected to job placement, training, and volunteer opportunities through the integrated platform. This rapid response helped residents understand their status quickly and prevented unnecessary disruptions in nutrition assistance. Staff were able to focus more time on complex cases rather than answering thousands of routine eligibility questions. Community-Informed Design: Systems That Reflect How Work Actually Happens The most sophisticated technology fails if frontline workers cannot or will not use it effectively. County agencies have spent millions on systems that

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PRACTICAL SOLUTIONS FOR CHILD WELFARE 5 WAYS STATES CAN ENSURE EVERY CHILD HAS A HOME

A

cross the country, child welfare systems are entering a pivotal moment. Recent

federal initiatives, including the Administration for Children and Families’ A Home for Every Child and new federal performance dashboards, signal a shift away from compliance driven oversight toward outcomes that reflect children’s lived experiences. At the center of this shift is a simple but powerful question: Does every child have a safe, well-matched home?¹ One way this question is increasingly understood is through the relationship between the children who need place ment and the number of family-based homes available to serve them. When the children entering care outnumber licensed homes, systems often rely on temporary or congregate settings. This imbalance, called the homes-to children ratio, offers a practical lens for understanding system capacity. While states set policy direction and performance expectations, counties and local agencies carry out that work on the ground. Workforce shortages and placement capacity challenges have exacerbated this imbalance. Aligning policy, practice, and data at the state level helps local agencies strengthen capacity and ensure every child can grow up in a family setting. This article outlines five practical ways states can lead that align ment using prevention, kinship care, data, permanency, and modernized technology.

BY AMY DRAPCHO

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1.

Invest Earlier: Prevention as Capacity-Building The most effective way to strengthen placement capacity is to reduce unnecessary entries into foster care. Prevention services such as housing support, behavioral health care, and economic stabilization can help families remain together. A growing body of research suggests that many child welfare cases stem from poverty-related hardship rather than abuse. Families experiencing housing instability, food insecurity, or unmet medical needs are more likely to come into contact with child protective services (CPS). In fact, more than 83 percent of families investigated by CPS have incomes below 200 percent of the federal poverty level.² Researchers and advocates increasingly note that poverty is often mistaken for neglect, particularly when families lack access to basic supports. For states, this distinction matters. When economic hardship is treated as maltreatment rather than a need for support, children may enter foster care even when services could have helped them remain safely at home. Prevention intersects with another major pressure facing child welfare systems: behavioral health. Many agencies report that the real bottleneck in foster care is the availability of homes equipped to care for children with sig nificant behavioral health needs. Parental substance use and untreated mental health conditions now play a major role in foster care involvement, particularly for infants and young children. Nationally, nearly two out of five removals involve parental alcohol or drug use, and among infants the share is more than half.⁸

When states invest in these upstream services, they help families remain together while protecting overall foster care capacity. Fewer unneces sary removals mean the system can better serve children who truly cannot remain safely at home. Research also suggests that children who remain safely with their families experience stronger long-term outcomes than similarly situated children placed in foster care.³ Removal itself can introduce trauma, disrupt relationships, and weaken community ties.⁴ At the state level, data can guide prevention investments. By examining referral patterns, economic indicators, and service availability, leaders can identify where families are most at risk of separation and target supports accordingly. Aligning prevention funding with federal initiatives such as the Family First Prevention Services Act reinforces this shift toward early intervention and family well-being.¹ Ultimately, prevention is not just about caseloads. It is about ensuring that children remain safely connected to the people and communities that know them best. Capacity, Not Just Definition When children cannot safely remain with their parents, relatives are often the most stable and familiar option. Kinship care has long been a corner stone of child welfare policy, yet many systems still struggle to identify and support relatives early enough. Children placed with relatives expe rience greater stability and stronger long-term connections to family and culture, and they are more likely to reach permanency than those in non relative foster care.⁵ “We are seeing states shift from simply trying to find more beds to rethinking the front door of the system,” said Sixto Cancel, Founder and CEO of Think of Us. “When foster homes are limited, the answer is not just recruitment. It is prevention 2. Sixto Cancel Strengthen Kinship Care by Expanding

and immediate engagement of rela tives. When kin are identified and supported from day one, children experience fewer moves and shorter stays, and pressure on the foster care system decreases. Kinship cannot be a backup plan. It has to be the first conversation.” Turning kinship into a true capacity strategy requires more than identifying relatives. States must invest in the supports that allow those placements to succeed. Clear licensing pathways, navigator programs, financial assis tance, and practical resources for caregivers all play an important role. “Supporting kinship families through evidence-based kinship navi foster care, while prior itizing kin finding and licensing will increase the number of available foster homes for every child who needs one,” said Ana Beltran, Director of the Grandfamilies & Kinship Support Network at Generations United. Additionally, practice tools can help. Genograms, family network mapping, and modern case manage ment systems allow workers to quickly identify relatives and maintain vis ibility into family relationships. These tools expand placement options and reinforce the goal of keeping children connected to their families and communities. Kinship care also intersects with equity. Children of color remain dis proportionately represented in foster care, making family-centered solutions particularly important for addressing longstanding disparities. Use Data That Drives Decisions— Not Just Compliance Historically, child welfare data systems have focused heavily on compliance reporting. Accountability remains essential, but federal leaders are increasingly encouraging states to focus on a smaller set of meaningful indicators that reflect real outcomes for children and families.¹ 3. Ana Beltran gator programs is a key strategy in decreasing the number of children who need to enter

Amy Drapcho is the Senior Manager of External Affairs at Northwoods.

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