Policy & Practice | October 2021

The Magazine of the American Public Human Services Association October 2021

Navigating Upstream Achieving Better Health and Well-Being Through Prevention

Our Dream Deferred Fulfilling The Nation’s Promise

WITH

American Public Human Services Association

What Happens to a Dream Deferred? Poet Langston Hughes posed this question 70 years ago, asking what might happen if our nation’s offer of endless possibilities—our American Dream—remains out of reach and unrealized for many. APHSA’s new podcast series, Our Dream Deferred: Fulfilling the Nation’s Promise , explores these prescient questions by engaging with brilliant minds from a wide range of elds. Seeking a new way forward that will bring us closer to ful lling the American Dream for all, we’ll explore themes that get at the heart of what we’re experiencing:

• American Narratives around Race and Class • Human Behavior and Social Norms and How They Change • AI, Social Media , and the Race to the Bottom of the Brain Stem • Democracy and What Is Working Against It

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contents

Vol. 79, No. 5 October 2021

features

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From Program to Person-Centered A Paradigm Shift in the Health and Human Services Industry as a Pathway to Prevention

30 Days to Family® The Unbuilt Bridge—Scaling Government-Involved Programs in the Space Between Institutional/ Foster Care–Based Services and Preventive Services

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The Time for Change Is Now Letting the Story Drive the Solutions

Family First …Second Finding a Solution to Managing the Workflow

departments

3 President’s Memo Connecting Our Work to Environmental Justice

24 From Our Partners

Focusing on Family Well-Being: A Conversation with Susan Gale Perry

5 Technology Speaks

25 Staff Spotlight Trinka Landry-Bourne, Organizational Effectiveness Consultant

Child Tax Credit as a Prevention Strategy: Spotlight on Tech Tools Boosting the CTC’s Reach

6 From the Field Hello Baby: Using Data and Proactive Outreach to Assist Babies and Their Families 7 Research Corner Prevent Child Maltreatment: Reducing Poverty Through Income Support Policies

26 Staff Spotlight

Jordan Ahmad, Membership Engagement Operations and Marketing Manager

32 Association News Bruce Liggett, Maricopa County Human Services Director, Retires

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October 2021 Policy&Practice

Strategic Industry Partners

APHSA Executive Governing Board

DIAMOND

Chair David A. Hansell , Commissioner, New York City Administration for Children's Services, NewYork, NY Treasurer Reiko Osaki, President and Founder, Ikaso Consulting, San Bruno, CA Leadership Council Chair S. Duke Storen, Commissioner, Virginia Department of Social Services, Richmond, VA Member At-Large Rodney Adams, Principal/CEO, R Adams & Associates, Indian Land, SC Immediate Past Chair David Stillman, Assistant Secretary, Economic Services Administration, Washington Department of Social and Health Services, Olympia, WA

Elected Director Derrik Anderson, Executive Director, Race Matters for Juvenile Justice, Charlotte, NC Elected Director Anne Mosle, Vice President, The Aspen Institute and Executive Director, Ascend at the Aspen Institute, Washington, DC Elected Director Katherine H. Park, CEO, Evident Change, Madison, WI Elected Director Dannette R. Smith, CEO, Nebraska Department of Health and Human Services, Lincoln, NE Elected Director Jennifer Sullivan, Senior Vice President, Strategic Operations, Atrium Health, Charlotte, NC

PLATINUM

SILVER

MEDIA

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Policy&Practice October 2021

president‘smemo By Tracy Wareing Evans

Connecting Our Work to Environmental Justice

T he impact of extreme weather has made headlines all too frequently over the past few years— from countless fires in the West, to once-in-a-century flood events occur- ring across the United States, to the devastating impact of Hurricane Ida stretching from the Gulf Coast to New York. All around us, we see the inten- sity of storms and fires growing rapidly and more frequently. The correlation of the impact of these events on our health and well-being is increasingly apparent, as is the need to under- stand the role of human services in promoting an equitable recovery and

To do so, we must first do more to understand the intersection of human services and environmental justice. In August, HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) published a new infographic (see above and online at https://aspe.hhs.gov/reports/ej-human- services ) illustrating this very

strengthening the resiliency of people and communities. The theme of this issue is Navigating Upstream: Achieving Better Health and Well-Being Through Prevention . In it, we feature articles that focus on improving overall health by advancing well-being, preventing harm, and advancing equity. As I write this column, it has never been clearer to me that if we are to truly get upstream, we have to be much more intentional about connecting our work to environmental justice (see https:// www.epa.gov/environmentaljustice/ learn-about-environmental-justice).

intersection, and why it matters. As I studied the infographic, I

reflected on my own life journey which has so often met at this intersection,

See President’s Memo on page 28

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October 2021 Policy&Practice

Vol. 79, No. 5

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Policy & Practice™ (ISSN 1942-6828) is published six times a year by the American Public Human Services Association, 1300 N. 17th Street, Suite 340, Arlington, VA 22209. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2021. 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 1300 N. 17th Street, Suite 340, Arlington, VA 22209

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Policy&Practice October 2021

technology speaks By Jess Maneely

Child Tax Credit as a Prevention Strategy: Spotlight on Tech Tools Boosting the CTC’s Reach

T he American Rescue Plan Act of 2021 expanded the Child Tax Credit (CTC) to put more money in the pockets of parents and caregivers in the form of monthly payments until December 2021. The largest Child Tax Credit ever, this expanded CTC is primed to advance prevention strategies and support upstream approaches to achieving better health and well-being. Advance CTC payments are already demonstrating positive effects on social determinants such as improved nutri- tion and decreased economic hardship, according to new Census data from the Household Pulse Survey. Food insufficiency and financial hardship immediately dropped after families received monthly disbursements, which overwhelmingly went to addressing unmet basic needs like putting food on the table, according to the same data. Meanwhile, recent Urban Institute analyses estimate the expanded CTC could reduce child poverty by more than 40 percent. To realize this impact, it is essential that the CTC reach eligible individuals who do not normally file income taxes and therefore may not automatically be receiving the credit. Unfortunately, Treasury data from June 2021 reveal at least 2.3 million families could be missing out. Human services agencies serve many of these families every day and are well positioned to deploy resources on the ground to assist eligible individuals. Technology-enabled, data-informed tools and resources are being rapidly developed to aid in this effort. To show what’s possible and inspire continued

Screenshot of the GetCTC interface for families to file for child tax credit payment.

urban.org/eitc-population ) visualizes where children are at risk of missing out on CTC. Free and available for public use, the easy-to-use tool allows users to zoom into zip-code-level views, and even download the full dataset for all states. Helping families file for CTC Launched in collaboration with the White House, U.S. Department

innovation, we feature two examples of new tools and highlight two instances of how health and human services agencies are using technology in creative ways to identify potentially eligible households and supporting families in filing for the credit. Finding families most at risk of missing out on CTC Developed by the Urban Institute- Brookings Institution Tax Policy Center, a map tool ( https://tpc-eitc-tool.

See CTC on page 27

Image via GetCTC.org

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October 2021 Policy&Practice

from the eld By Amy Malen

Hello Baby: Using Data and Proactive Outreach to Assist Babies and Their Families

E fforts to support families with newborns are plagued by a familiar problem in social services: the people who most need the help rarely ask for it. The Allegheny County, PA Department of Human Services (DHS) has combined its service, outreach, and data resources to create an innovative response to this problem. In September 2020, DHS launched Hello Baby, a voluntary program designed to connect families and their babies to the best available supports and thereby improve child outcomes, safety, and security. Hello Baby is a collaborative partnership between DHS, the Allegheny County Health Department, and several com- munity partners, including Healthy Start, Family Centers, United Way 2-1-1, and others. Allegheny County has a rich array of supports for families. But because engaging families is challenging, many have never participated in preven- tive community services or received even light-touch interventions. The programs designed to serve families with the most complex needs tend to end up attracting less needy families instead. For example, prior to the implementation of Hello Baby, only 27 percent of children enrolled in Allegheny County’s home visiting programs were classified as having high or complex needs. Hello Baby was driven by awareness that in child welfare, if you wait for the first crisis before intervening, it’s often too late. In half of all Allegheny County cases involving a child’s death or serious injury due to abuse or neglect, there was no referral or

ensures that uninterested families will not be contacted. Hospital staff can refer high-need families identified around the time of delivery and DHS uses a predictive risk model (PRM) to select families for proactive outreach. The PRM draws on data from birth records, protec- tive services, homeless services, the justice system, and others to estimate each family’s likelihood of a serious adverse child outcome by the child’s third birthday.

request for assistance before the tragic incident occurred. To better connect families to the services that best meet their needs, Hello Baby has implemented a tiered strategy with both broad and targeted forms of outreach. Every parent delivering a newborn in an Allegheny County hospital receives a Hello Baby gift bag with program information. In addition, using birth record data, DHS sends a postcard to each family a few weeks after delivery, reminding them of the program and the resources available. An opt-out option

See Hello Baby on page 25

Photo via Shutterstock

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Policy&Practice October 2021

research corner By Nicole L. Kovski, Heather D. Hill, Stephen J. Mooney, Frederick P. Rivara, and Ali Rowhani-Rahbar

Prevent Child Maltreatment: Reducing Poverty Through Income Support Policies

C hild maltreatment impacts a significant share of children and families in the United States. In 2018, 7.8 million U.S. children were the subject of an investigation for suspected abuse or neglect by child protective services (CPS). 1 Over the course of childhood, an estimated 37 percent of all U.S. children will experi- ence at least one maltreatment-related investigation 2 and 12.5 percent will be deemed victims of maltreatment by CPS. 3 Maltreatment has numerous consequences for children, including adverse cognitive, emotional or behav- ioral, social, and economic outcomes throughout the life course. Poor children experience mal- treatment at higher rates. Economic hardship can increase maltreatment risk directly by impairing caregivers’ ability to adequately meet children’s basic material, safety, medical, and supervisory needs. It can also increase risk indirectly by increasing parental stress, which can, in turn, lead to harsh or neglectful parenting. Given the strong link between families’ economic circumstances and maltreatment risk, public policies and programs that are designed to reduce poverty may prevent the occurrence of child maltreatment in the United States. While no single policy can eliminate child maltreat- ment, income support policies have been proposed as an efficient and effec- tive approach for primary prevention. 4 Evidence from the Earned IncomeTax Credit In the United States, the largest income support program for working families with children is the federal

rates of reported child maltreat- ment. We used administrative data on maltreatment from the National Child Abuse and Neglect Data System (NCANDS), which contains a record of all “screened-in” reports of maltreat- ment (i.e., reports that met agency criteria to warrant further investiga- tion) in nearly all U.S. states from 2004 through 2017. We considered overall maltreatment report rates as well as specific types—neglect, physical abuse, emotional abuse, and sexual abuse, and child ages—0–5 years versus 6–17 years). Our study found that greater generosity of state EITC benefits was associated with reduced rates of maltreatment reports made to CPS. A 10-percentage point increase in the generosity of refundable state EITC benefits was associated with 241 fewer reports of neglect per 100,000 children

Earned Income Tax Credit (EITC). The EITC is a refundable tax credit that is conditional on employment and available to low- to moderate-income working families. In 2020, the average credit was $2,461 per household, but the maximum credit for families with three or more children reached $6,660. The EITC lifts millions of individuals out of poverty, including three million children, every year. 5 In addition to the federal EITC, 30 states and the District of Columbia have state EITCs, typically offered as a percentage of the federal EITC. A considerable body of research suggests that EITC benefits have positive spillover effects on families’ well-being, including improvements in children’s health and developmental outcomes. 6 In a recent study published in Child Maltreatment , 7 we investi- gated whether the generosity of state EITC benefits (the percentage of the federal credit) influenced state-level

See Income Support on page 31

Photo via Shutterstock

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October 2021 Policy&Practice

A Paradigm Shift in the Health and Human Services Industry as a Pathway to Prevention From Program to Person-Centered

By Leah Dienger

ront-line health and human services workers have long known that improved health and well-being is best achieved by assessing and providing coordinated services in an integrated care framework. It is the way risks and root causes can be fully understood. Cost-effective prevention and early intervention strategies can be achieved, providing long-term physical and mental wellness. Knowing that a person- centered approach renders the best outcomes, it is important to reflect upon what is impeding our progress. F

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October 2021 Policy&Practice

Person-Centered Care Delivered Within a Connected H/HS Ecosystem

The Current State: Siloed Service Delivery Coordinated care and a multidisci- plinary team (MDT) approach gained popularity in the health and human services (H/HS) industry during the late 1980s and early 1990s. Yet, despite the success of holistic assessments and treatment with vulnerable individuals and families, delivering H/HS services in silos remains. Burdened with policy, program, and data-sharing barriers, H/HS workers have found it easier to operate in programmatic isolation instead of facing intense barriers to work collaboratively. Well-intentioned singular service providers continue providing for singular needs the best that they can. Meanwhile individuals

again. She leaves out some details when she becomes weary. For some programs she is eligible—for others she is not. The process is lengthy and tiresome. There are different documentation require- ments for each program and she cannot keep up with all of them. Her children are wearing her out. She doesn’t have time to look for another job. Only a portion of her needs is met before frus- tration sets in and she gives up on the process, left in a state of crisis. This type of siloed, uncoordinated care has serious consequences for this mother. It applies equally to other vulnerable populations that are challenged by addiction, untreated mental health disorders, homeless- ness, reentry to society from jail or prison, youth in the juvenile justice system, and many more. Fragmented data and disconnected care networks are reasons individuals in need grow tired and give up—only to cycle back around when the next crisis hits. It is a contributing factor for frequent high-cost crisis care and long-term utilization of social programs’ over- strained budgets. Siloed data are sparse, fragmented, and unconnected among the various organizations, thereby denying providers access to

in need struggle on their own to navigate a complex system of siloed service delivery. Take, for example, a mother who loses her job due to lack of affordable child care. Her pantry cabinets are bare. She arrives at a food bank and receives a bag of groceries. Her imme- diate need is met—with a band-aid fix. Yet without working upstream to address her needs holistically, she con- tinues to the next crisis: when there is no money to pay rent and she and her children become homeless, or when other challenges arise from her situ- ation and the overwhelming stress of single parenting comes to the attention of a child welfare agency. Let’s imagine if this mother does seek services on her own. She spends hours making phone calls, scouring the internet, and seeking transportation in search of available services that are not easily located. She fills out numerous benefits applications. She goes from door to door for each of the needs she identifies are important while not rec- ognizing other needs that also threaten her family’s wellness. Since the agencies are siloed and do not have access to what she has shared elsewhere, she shares her story and data over and over

Leah Dienger , MSW, is a Senior Consultant at IBM on the Health and Human Services Public Market team.

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Policy&Practice October 2021

housing, employment, and health and human services. Consent and authoriza- tion features that conform to applicable Health Insurance Portability and Accountability Act privacy laws and policies are implemented using HL7 FHIR data standards. Individuals with complex needs, including mental health challenges, homelessness, economic instability, and criminal justice involve- ment have been among the first cohorts to engage with the overall solution of a person-centered, coordinated care service delivery model. In a short period of time, we are already seeing incredible results: increased services to more than 6,600 individuals, reduced recidivism, a 32 percent cost decrease in local Emergency Departments from high utilizers for non-emergencies, and a 7 percent drop in homelessness from 2019 to 2020. “If I could tell the number of stories of the stressors and pressures that vulnerable people feel in terms of trying to navigate all these different systems and programs—thismodel has reduced that pressurewitha nowrong door approachand is allowing for us to havemore success andhaving teams thinkmore holistically about how tomeet the needs of vulnerable individuals. We’ve been very successful ina short period of time.” —BARBIE ROBINSON, (FORMER) DIRECTOR, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SONOMA COUNTY The outcomes of enabling an inte- grated, coordinated care network of service providers speak for themselves in a cohort of repeat criminal offender population: “This is unbelievable.We’ve had people that were ten-time repeat offenders; they haven’t repeated once. They haven’t been pickedup once. Our recidivism isway down. All the peoplewho were enrolled in this cohort, none of themhave had jail time

since they started participating with the Interdepartmental Multidisciplinary Teamand the mental healthdiversion cohort.” —CAROLYN STAATS, INNOVATION DIVISION DIRECTOR, SONOMA COUNTY Leveraging system and data integra- tion allows caseworkers, substance abuse counselors, and eligibility workers to coordinate quickly and com- municate seamlessly without impact to their organization’s native IT systems. “What IBMdesigned for us, the RapidResponse system(ACCESS Sonoma), is the solution that wewere looking for. It nowenables us to have coordination between caseworkers and substance abuse counselors and eligibilityworkers, and to do it rapidly sowe can get that person back on their feet again.” —SHIRLEE ZANE, BOARD OF SUPERVISORS, DISTRICT 3, SONOMA COUNTY The Future State: Person- Centered, Preventive Care Driven by Shared Data The combined impacts from SDOH, health inequities, ACEs, homeless- ness, mental and physical health, and economic instability make attaining long-term health and wellness in siloed service delivery impossible. Leveraging the public health model at the fore- front of the pandemic efforts, H/HS can take away best practices through the approach of identifying risk indi- cators for the prevention of illness, and holistic person-centered care to address complex needs. Public health also works across disciplines, including health, education, and social services, which makes it a good model to inform an H/HS service delivery model shift. An alignment to the public health model means that H/HS can adopt at scale a common mission to reduce the impacts of risks and increase the poten- tial for well-being—prevention and early intervention delivered through a compassionate, connected network of service providers fueled by a common See Person-Centered Care on page 30

the whole-person view they need to achieve improved outcomes. Gaps in care are inevitable and opportunities to intervene before problems arise are missed. Vital needs go unmet and poverty, hunger, addiction, homeless- ness, and mental instability remain escalated and expensive for both the individual’s overall health and the entire H/HS ecosystem. Mindset: A Shift in Delivery Models Confronted with new faces of need and the sheer numbers flocking to assistance programs throughout the pandemic, many are questioning the blaring inefficiencies of current policies, processes, and siloed data collection. Meanwhile, conversations around prevention and early intervention strategies from a public health point of view are becoming the norm across the nation to keep individuals, families, and communities safe from illness and provide long-term physical and mental wellness. What is emerging louder than before are the effects of social deter- minants of health (SDOH) and adverse childhood experiences (ACEs) on an individual’s well-being, as well as the importance of the need for fairness, equity, and just treatment of all races in current H/HS service delivery. IBM and our partners are creating innovative ways to overcome the typical policy, program, and data- sharing barriers. To achieve better outcomes, H/HS must shift to accom- modate the knowledge around SDOHs, health equity, ACEs, and acknowledge their impacts on whole-person well- being. Health and human services must address health equity and aim toward interventions that are fair and equitable for all. And finally, H/HS must explore options to securely integrate data across organizations, turning quality data into insights that initiate prevention and early interven- tion actions that drive reduced costs and life-changing outcomes. A great example of success is IBM’s work with Sonoma County to create the ACCESS Sonoma initiative and system (https://sonomacounty.ca.gov/CAO/ Projects/ACCESS-Sonoma/) . Underlying technology enables the integration of source system data that includes

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October 2021 Policy&Practice

uman services agencies are grappling with chal- lenges at an unprecedented level. With efforts to serve NOW The Time for Change Is H Letting the Story Drive the Solutions By Todd Ellis, Carole Hussey, and Rachel Pratt

families in the midst of a global health emergency, calls to address structural racism and bias, and implementation of new benefit programs in extraordinary timelines, the time for change of an outdated system of support is now. The national human services call to action is to move services and supports upstream, allowing individuals and families to access them when the need first arises, stemming later, more signif- icant interventions, from downstream systems of care designed to respond to crisis. A client’s story and their journey shape who they are, how they would like to be engaged, and what services may be valuable to them.

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October 2021 Policy&Practice

Opportunities for Action The issues have been documented at length. This article focuses instead on actions that state and local agency leaders and staff can take now. We are at a pivotal moment to use the current opportunities presented to us to effect real change. These opportunities result from: ■ The COVID-19 pandemic and the light it shone on individuals, families, and communities, both in its disproportionate impact and increased numbers of individuals needing support due to illness, job loss, inadequate child care, and more ■ The urgent call to action to end racism and racial bias, including racial bias in human services policies, practices, and systems ■ A broader understanding of how negative social, economic, and envi- ronmental factors correlate with poor health ■ Better and more affordable access to data and technology solutions, including transparent and ethical uses of artificial intelligence and machine learning, facilitating com- munication across previously siloed systems and improving predictive recommendations. 2 Atlanta-based Morehouse School of Medicine (MSM) noticed the opportunities for action and is moving upstream in their fight against COVID-19 and its larger impacts in underserved communities. Recognizing that historic inequities in health care, housing, education, and income exacerbate the impact of the pandemic on already underserved communities, MSM collaborated with KPMG, Salesforce, and a network of community-based organizations and other partners to create a commu- nity health portal called the National COVID-19 Resiliency Network (NCRN). “Through its partnerships, the NCRN is a digital front door for individuals and families in underserved communities to access COVID-19 related resources that are culturally and linguistically appropriate,” says Dominic Mack, MD, MBA, Director of the National Center for Primary Care and Professor of Family Medicine at Morehouse School of

Medicine. Partnerships are a crucial part of the solution, as Dr. Mack explains: “We’ve partnered with community- based organizations because they have a presence and a reach locally, understand why community members don’t come forward, and, through their credibility and trust, they can link communities they serve to critical health education information and care options.” The NCRN leverages the power of technology to engage communities at the zip-code level (in 11 different languages), connecting people to the information and resources they need to get health education resources, access to primary care providers, and a view into their state’s vaccine distribution pipeline. This solution provides health systems with access to sometimes hard-to-reach communities by empow- ering themwith information on how to navigate the system, manage cases, assess demand and supply for services and vaccines—all ultimately to improve community health access and outcomes. While at first glance the MSM project is about data and technology, it is fun- damentally about catching problems early and providing solutions that are appropriate and accessible. At the core of the MSM project are the populations that it serves, including African American, Latinx, Asian Pacific Islander, Alaskan American, and Native American populations. These groups have been historically underserved, are disproportionately impacted by the pandemic, 3 and continue to suffer from far higher rates of many preventable and treatable medical conditions such as diabetes, hypertension, and asthma. 4 The team set out to create an experience designed by, about, and for them. Todd Ellis, Principal at KPMG, states, “The platform is seen as a living, breathing thing that will evolve based upon continual feedback. What’s working can be measured, and appropriate adjustments can be made based on platformmetrics. Each local community can share best practices to maximize the engagement of its citizens. The hope is that in capturing the voice of the traditionally voiceless, these insights can be used in the plat- form’s continuation post-COVID—to promote health at the community level.”

There is a disconnect between the vision and the current reality for many individuals and for the agencies pro- viding these services. Human services leaders across the country are plagued by a history of siloed delivery models, policies, and funding limitations that deliver fragmented remedies to indi- viduals and families far downstream. At the point of intervention, relatively simple problems have grown in scope and the impact on lives is far greater than when the original issue was pre- sented. Problems that appear to be social in nature, if left unaddressed, compound and negatively impact health in the long and short term. Racism and racial bias have led to the disproportionate representation of people of color in downstream systems, resulting in exposure to social and environmental factors that negatively impact health. 1

Todd Ellis is the Principal,

Advisory Health and Government Solutions, at KPMG LLP.

Carole Hussey is the Director, Government

Solutions, Children and Family Services Lead at KPMG LLP.

Rachel Pratt is the Manager,

Advisory, Health and Government Solutions at KPMG LLP.

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Policy&Practice October 2021

5. Tell Your Stories Never let the wealth of data and technology minimize the importance of strong leadership, meaningful ques- tions, data quality, and respectfully telling the story of the people you serve. The people being served have a story that began long before they became known to the agency. Candid and open conversations about these experiences will create a groundswell to disrupt the status quo and begin to reconsider innovative models for serving and sup- porting our fellow humans equitably. A renewal of authentic engagement will lead toward a collaborative and trusted environment, providing a platform for much needed change. This vision and call to action has never been clearer than it is today. KPMG LLP has long recognized and supported its clients in their efforts to promote child and family well-being through primary prevention and early intervention. As the data, practices, and technology necessary to bring this vision to life in communities around the country are available and far more reliable and affordable than in the past, the time for change is now. Using past history to guide us and the opportunity that is before us, we can write a more optimistic story for the future—a journey toward economic mobility, self-sufficiencies, and thriving communities. (2021). Child welfare practice to address racial disproportionality and disparity. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau. https://www.childwelfare.gov/pubs/ issue-briefs/racial-disproportionality 2. Uzzi, B. (2020). A simple tactic that could help reduce bias in AI. Harvard Business Review. https://hbr.org/2020/11/a-simple- tactic-that-could-help-reduce-bias-in-ai 3. APM Research Lab. (2021, January 7). The color of coronavirus: Covid-19 deaths by race and ethnicity in the U.S. https://www.apmresearchlab.org/covid/ deaths-by-race 4. Centers for Disease Control and Prevention (2021). Health equity considerations and racial and ethnic minority groups. https://www.cdc.gov/ coronavirus/2019-ncov/community/ health-equity/race-ethnicity.html Reference Notes 1. Child Welfare Information Gateway.

and practice perspective, as well as for clients, providers, community partners, and staff. Human-centered design (HCD) is an increasingly adopted practice to design technology solutions, programs, and client experiences to optimize delivery. Cornerstone practices of HCD are user research, whereby both qualitative and quantitative data are collected to inform processes, and prototyping, whereby concepts are turned into tangible simulations to spark creativity and iterate on ideas. Human services leaders learned long ago that moving upstream requires bridging silos. There is, however, much work to be done to serve clients more holistically and effectively. While standards for data sharing, such as the National Information Exchange Model for Human Services and the National Human Services Interoperability Architecture, exist to make efficient information exchange across diverse public and private health and human services organizations a reality, adoption is still lagging. And while confidentiality and privacy remain paramount considerations when sharing an individual’s data and must be addressed in any data-sharing scenario, the technology exists to address those concerns. 4. Elevate the Use of Data Once silos are connected, data tools allow us to elevate our use of data far beyond answering questions about our single agency interactions with the people we serve. With access to real-time data and solutions to bring together data from multiple sources, it is possible to gain a more holistic view of clients and the multiple programs with which they interact. If we then add community-level data and apply machine learning algorithms and pre- dictive analytics, then data become useful because they allow workers to have that complete picture of which individuals might be more likely to need specific services and understand why they are needed. 3. Build Bridges to Connect Silos

At its start, there were 50 partner organizations; now there is a growing network of more than 200 community- based organizations, health care facilities, and academic institutions that make up this large national network. The Future State We must consider the story of those we serve as we design the future journey in a system of care. The MSM collaboration is one example of this innovative upstream thinking, at a community level. MSM presents a future state envisioned by many in the field: a service delivery model that is equitable, human centered, and outcome focused. It is offered with dignity and without judgment and sup- ported by processes and technology that are efficient and cost effective. Achieving a future state that allows individuals and families to access services and supports when the need first arises can be daunting. Nevertheless, agency leaders and staff can start taking meaningful steps today to build on upstream efforts by incorporating the five actions high- lighted below. Give individuals with lived experi- ence in the human services system a meaningful place at the table as you plan, design, develop, implement, and evaluate programs. When lived experience perspectives are included, and time is invested to engage in open and transparent communication, the quality, impact of services, and ability to develop innovative approaches are vastly improved. Your programs will not only be more focused, integrated, and culturally appropriate but also be more accepted and sustainable. 2. Design for Outcomes The meaningful involvement of people with lived experience is the first step in designing outcome- focused programs and solutions rooted in equity. Designing for mean- ingful and measurable outcomes involves defining target outcomes at the beginning. Outcomes should be contemplated from both the program 1. Engage People with Lived Experience

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October 2021 Policy&Practice

30 Days toFamily®: The UnbuiltBridge

Scaling Government- Involved Programs in the Space Between Institutional/Foster Care-Based Services and Preventive Services

By Ian Forber-Pratt and Melanie Moredock

We

suspect that all of us are seeing unanticipated challenges and roadblocks in the transition from institutional/foster care–based services and preventive services. But we are

unapologetic optimists and wanted to frame this article as a thought experiment around the unbuilt bridge needed between our starting point—congregate care and foster care as prominent ways of care and protection for children in the child welfare system—to community-based and prevention-focused care.

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efficiently shift their service provi- sion within child welfare. 2 30 Days to Family®, a program that works at the point of entry into care, is just one program of many that will help the United States effectively move to achieving better health and well-being through prevention, by infusing the philosophies eventually needed in prevention into the current workings of the system. The sub-theme of this article is that programs must be designed for scaling in order to support the sustainability of the child welfare system’s pivot to prevention. But first, in order to fully contextualize this article that focuses on replication and the importance of programs in transi- tion aspects of care reform, we have to share a bit about the program. The 30 Days to Family® program is an intense family search & engagement + kinship navigation program that springs into action the moment a child enters care. More than 70 percent of children served get placed with rela- tives or kin within 30 days of entering care. Perhaps even more important, after being placed with a relative, 81.7 percent of children served remain stable in their placement. 3 At this point, the 30 Days to Family® program is more than 10 years old, and frankly, it works. It works in large part due to some incredibly unique aspects of the model that could very well be implemented into any family search and engagement process to promote best practices: ■ Working with only two families at a time allows the specialist to identify an average of 150 family members in every single case. ■ Contact is made with all family members identified. Every single one. They all have something to con- tribute—regardless of their situation or background. ■ Urgency is key. Services last for 30 days. Period. We get in, we do the work, and we hand off, without sac- rificing thoroughness. Every night a child spends in foster care is a night in crisis. ■ Connections and supports are valued as much as family placement options. Families are used to sup- porting each other naturally, we just have to give them the opportunity.

We write about what we know, so this article uses the 30 Days to Family® program rollout in a U.S. county-administered system as a case example. We use current data, real examples, and heart-based language in the hope of making this come alive. So let’s start with the Families First Prevention Services Act of 2018. Any seismic shift of this nature takes considerable time, resources, inten- tionality, and examination. Obvious, right? But sadly, our systems often cannot account for the logical difficulty and time it takes for systemic change to occur. We’ll start up at the global level and then get down to the ground. For the last few decades, the alterna- tive care reform movements globally have increasingly given focus to the need for positive outcomes but also intentionality around the how and timelines of care reform. 1 Social change theory and human-centered design have begun to take a front seat in conversations. Global researchers have begun to study and compare care reform movements and focus on key learning/guidance for how countries

■ Because the system is tough to navigate, we help families access, map, and sustain every service they need. ■ The tone is set with the family that they, not the professionals, are the experts on their families, and that they are partners of the child welfare system, not clients. Their participa- tion is essential for children to have positive outcomes, both now and in the long term. ■ The program is implemented by a specialized worker for this special- ized work. One person doing all the jobs needed for robust family search & engagement, plus all of the other daily case management duties, isn’t possible. With the Families First Prevention Services Act of 2018, programs like this and others in the bridge space between institutions/foster care and prevention started to get increased attention. This particular program started in St. Louis, MO, at the Foster & Adoptive Care Coalition in 2011. Since 2011, for those children and youth served by the program, more than 75 percent of them achieved placement with family! And at the time of follow up, 82 percent of those children remained living with family! Additionally, an independent study found that children served by the program exited foster care faster as well, thus saving taxpayers more than $10,000 on average for every child served. For youth age 9 and older and those youth with an identified disability, the savings increased to an average of $21,686 and $28,819 respectively! So, state and county administrators started to show interest. In 2019, Ohio’s Attorney General at that time approached Kinnect (a nonprofit organization) with a problem—there weren’t enough foster homes for all the children in foster care in Ohio. He asked Kinnect for guidance on how to recruit more foster homes. Kinnect wisely saw this as an opportunity to influence and redirected the conversation: If the focus shifted to finding family members to care for youth, there would be no need to recruit additional stranger foster homes. The Attorney

Ian Forber-Pratt , MSW, is the Chief Executive Officer of the Institute

for ChildWelfare Innovation in St. Louis, MO, and is the Director of Global Advocacy of the Children’s Emergency Relief International (CERI).

Melanie Moredock is the Chief Operating Officer at the Institute for ChildWelfare Innovation, and is responsible for overseeing the day-

to-day operations of the company, as well as the replication of the groundbreak- ing 30 Days to Family® program.

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Any seismic shift of this nature takes considerable time, resources,

General not only listened, but provided the avenue for a pilot rollout of the 30 Days to Family® program in Ohio through the use of Victims of Crime Act funding. The rollout was ambitious: installation of the program in nine counties, spread all throughout the state, in just one year. The program, living in this bridge space, met a need for the state. But then the challenge of scaling the program came into intense relief. The success of 30 Days to Family® Ohio was based largely in part on the stage-based implementation process. With so many counties interested in replicating, the first step was to have a solid Exploration Process. This process started with speaking to each interested county and going through a Goodness of Fit assess- ment. Review of things like: what are the current intake numbers; how many of those children are not placed with family when they enter care; what is the county’s current buy-in to the importance of family place- ment; and most important; does the county’s policy allow for a child to be placed with family in 30 days? With Ohio being a county-administered system, the answers varied widely county-by-county. Once the Exploration Phase of the first few counties was complete, we moved into the Installation Phase. This included engagement with the key stakeholders of each county, hiring of the 30 Days to Family® staff, and training on the program. While in Installation with Phase 1 counties, Exploration of Phase 2 counties was also taking place. There were many moving parts, and there was not much time to take into account the lessons learned from the initial counties before interacting with subsequent counties. In essence, with a rollout this large, we were building the plane while we were flying. We didn’t realize how complicated and nuanced replication of the program on a large scale would be. With each new county coming on board, the processes became a little more defined, and then even more refined. When there are so many people doing the work, there must be one clear process and answers must be readily available at everyone’s

intentionality, and examination. Obvious, right? But sadly, our systems often cannot account for the logical difficulty and time it takes for systemic change to occur.

safer one for children, families, com- munities, and workforces. The 30 Days to Family® program was recently accepted into

fingertips. There were not enough hours in the day for a small replica- tion team to provide personalized attention to each and every question. Replication manuals were bolstered, supplemental trainings and Learning Communities were held, and fidelity measures were established. Once a tried and true process was in place, for each step of the implementation, 30 Days to Family® was easily integrated into the next county. Kinnect has supported 17 counties in the replication of 30 Days to Family® Ohio and is in the process of adding at least 5 more counties! 30 Days to Family® Ohio has also transitioned into a formal partnership directly with the Ohio Department of Job and Family Services. An independent study on the replication of 30 Days to Family® in Ohio was conducted and has been submitted for publication. The study demonstrates the same stellar results in Ohio, proving that the program and the results can be replicated! So now we return to the main thematic thread of this article, the need for programs that gently, but with evidence, guide the child welfare system “upstream.” The use of 30 Days to Family® gives one example of how a program can adapt and scale in a needed space. Now to the bigger message that the “space” is the unbuilt bridge. Globally, systems have seen decreased positive outcomes for children and families as rapid or drastic changes are rolled out on inhumane timelines. Our message of hope is that programs like 30 Days to Family® and many others exist in this unbuilt bridge and can help make the transition—that the Families First Act and other legislative pushes ask for—a

the California Evidence Based Clearinghouse with a rating of

“3—Promising Research Evidence,” under Permanency Enhancement Interventions for Adolescents, and a “High” relevance to the field of child welfare. The program is currently under consideration by the Title IV- E Prevention Services Clearinghouse. Please visit our website at www.forchildwelfare.org to learn more or contact Melanie Moredock at melanie@forchildwelfare.org . For information about Kinnect, please visit www.kinnectohio.org or contact Stephanie Beleal at stephanie.beleal@ kinnectohio.org. Reference Notes 1. United Nations General Assembly. (2019). Promotion and Protection of the Rights of Children. Seventy-fourth session. United Nations General Assembly. (2010, February 24). Guidelines for the Alternative Care of Children: Resolution/adopted by the General Assembly, A/RES/64/142 | United Nations General Assembly. (1989). United Nations General Assembly Convention on 2. van IJzendoorn, M., Bakermans- Kranenburg, M., Duschinsky, R., Fox, N., Goldman, P., Gunnar, M., Johnson, …Sonuga-Barke, E. J. S. (2020). Institutionalisation and deinstitutionalisation of children 1: A systematic and integrative review of evidence regarding effects on development. The Lancet Psychiatry , S2215-0366. 3. Atkinson, A.J. (2019). 30 Days to Family®: Confirming theoretical and actual outcomes. Child Welfare, 97 (4), 97–129. the Rights of the Child, UN document A/RES/44/25 United Nations (1989).

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October 2021 Policy&Practice

Finding a Solution to Managing the Workflow

By Bill Bott

I

believe that the Family First Prevention Services Act (Family First) is best for children and families. By changing the IV-E reimbursement rules we can encourage more early intervention, up-stream whole-family services, and thus drastically reduce the trauma caused by a removal. As a process improvement geek, I have been working with child welfare practitioners and champions for the last seven years and they, and their data, have convinced me that the goals associated with Family First are both noble and needed. I would never argue against them. I will argue, however, that if we do not fix our capacity crisis in child welfare, we may never see the results we hope for. It is essential that we address our capacity issue to maximize Family First.

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