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CHAPTER 11

Responding to Policy Change and Creating Policy Impact and Systems

Change Through Strategy Marilyn Mason-Plunkett, Timothy Johnstone, Barbara Vollmer,

Daniel L. Daly, and Rebecca M. Robuck

CREATING SYSTEMS CHANGE AND POLICY IMPACT THROUGH STRATEGY AT HOPELINK

The ground under nonprofits is shifting quickly and profoundly, especially for organizations with a mission to ameliorate or solve intractable social problems. In the current political and economic environment, the demand for increased and more measurable service impacts is greater than ever before, with agency and program funding increasingly tied to demonstrable success. This is ultimately a positive trend for the nonprofit sector, but it is a sea change in its operational implications for many nonprofits.

The scrutiny and accompanying demands for accountability will become even more intense as government budget woes deepen and performance- based contracting proponents become more common. To thrive during this period of change and uncertainty, savvy organizations are getting out in front of these changes and developing clear and effective long-term strate- gies to influence positive change in their communities and in their clients’ lives.

These high-performing organizations are learning that effective social change must come as a result of a collective effort, not the isolated interventions that have often been the more traditional approach to solv- ing specific social problems. In fact, studies of impact successes have led more and more often to the conclusion that large-scale social change only comes with better cross-sector coordination (Kania & Kramer, 2011). This recognition is causing a profound shift in thinking as organizations look

Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950. Created from ashford-ebooks on 2018-11-26 18:36:13.

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beyond their borders, not just to their peers in the nonprofit world but to other sectors as well, to look for solutions and for partners in achieving their missions.

This is much easier said than done, and many early attempts at collabo- ration met with failure. But the successes, those that resulted in the biggest impacts, had things in common worth noting and replicating. First and fore- most, these organizations not only wanted to help people in their communi- ties, but they also had an “unstoppable desire to create lasting impact as well” (Crutchfield & Grant, 2008, p. 24). In the most successful cases, this passion has led nonprofit leaders to a crystal-clear statement of mission and guided their thinking about the broad drivers of the impact they sought.

It has also become apparent that lasting impact requires a fundamen- tal change in the way the communities served by these nonprofits approach these problems. Ultimately, all sectors of the community—nonprofits, gov- ernmental entities, for-profit businesses, and individual citizens—must transform the way they approach and make decisions about policies, pro- grams, the allocation of resources, and, in the end, the way they deliver ser- vices to people who need them (Crutchfield & Grant, 2008, p. 6). This can be a daunting task, one that requires all stakeholders to develop and use new skills, learn how to lead and drive the necessary systems changes in their communities, and develop and execute broader strategies to guide them.

The complexity and scope of both the social problems that need to be solved and the collaboration necessary to solve them require a fresh approach to strategy development, planning, and execution.

Driving Systems Change Through Strategy

It all starts at home. Nonprofit organizations committed to driving lasting change must first develop a deep understanding of the nature of the broader problem. They must then clearly define what success looks like—including both their role and what others’ roles in the process might be. To do that, these organizations must develop a clear view of their target service areas, and they must also know who else in the community is serving the same cli- ent base and how those services are being provided.

The first step is developing a clear understanding of the theory (or theo- ries) of change that will yield the desired results. Having strong evidence that the broad approach and collective interventions suggested by the theory of change is important, for purposes of both internal alignment and external communication. To make lasting change for clients and the communities in which they live, theories must predict solid, positive impact on clients and the community—and they must deliver.

Many social problems that nonprofits want to affect defy easy measure- ment. Some are of a more technical nature, with well-defined issues and determinable solutions, so the answer is known in advance; these are social issues for which one organization, or a combination of several, has the ability

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Chapter 11 resPonding to PoliCy Change and Creating PoliCy iMPaCt 209

to implement a solution. However, the more complex, adaptive-style social problems that most organizations face are quite the opposite, with answers not fully known in advance and no single entity having the resources or authority to bring about the necessary change (Kania & Kramer, 2011, p. 39). As a result, successful organizations aren’t always able to immediately quan- tify their results but nevertheless work hard at rigorously assembling the combination of quantitative and qualitative evidence that enables them to track their progress (Collins, 2005, p. 7).

After the theory of change and the related success measures are estab- lished, the next step is to identify all the elements of change that must be influenced to yield the desired results for clients and the community, and then to determine the indicators of success for each such element. Logic models can be applied to each element of success to understand the combi- nation of interventions that may yield the best result. Because the theory of change may be quite broad in scope, care must be taken to include the timing and coordination of interventions that best benefit each client.

This thinking drives program changes as well. In the past, nonprofits may have painted clients with broad swaths, using generic, one-size-fits-all services with activity-based outputs and outcomes. The recognition that this approach is not as effective for driving permanent results for clients has trig- gered the realization for many agencies that their programs may need to be modified. In addition, this new approach may call for a significant shift in organizational culture. However, after these organizations understand the drivers of broader success, they can make much more effective choices about resource allocation.

At the core of program evaluation is the need to develop a deep under- standing of the organization’s own strengths, weaknesses, and passions, as well as those of other organizations and potential collaborators or partners. Because the adaptive issues that the nonprofit sector is facing today often require collective, cross-sector coalitions and the development of systematic solutions (Kania & Kramer, 2011, p. 39), developing an understanding of the collective competence of the resources in the organization’s service area is foundational to successful program development. And these areas of col- lective strength are where the opportunities for client success—and future funding opportunities—lie. This approach to program analysis can also lead to learning the key drivers of success for more narrowly defined groups of clients. Understanding which program interventions are most effective for clients of a specific age, gender, or cultural heritage can yield striking results.

Internally, the organization’s culture may need to evolve as it becomes ever clearer that the time of doing good work in a silo and simply reporting outcomes has passed. Smart agencies are by necessity becoming highly dis- ciplined and determined about leveraging their core strengths, strategically yielding their less effective activities to others having greater core compe- tencies in a particular arena. They also are making good but difficult deci- sions to shed less efficient and less effective programs in order to create the greatest impact possible with their available resources. At the same time,

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effective organizations are becoming more aware and adept at engaging in richer collaborations with others, all in the effort to yield greater impact on client outcomes.

This doesn’t happen on an ad hoc basis. When an organization under- stands itself and its role, it must create a strategy that can be shared and that will work to transform the thinking of others. Interventions directed at system improvements are likely to be more practical and realistic in today’s resource-constrained environment (Fleming et al., 2010, pp. 1–2). A recent U.S. Justice Department study suggested that to transform a community’s systems, all five of the following strategic elements must be created or change simultaneously:

1. Joint governance and shared decision making 2. Cultural competence 3. A unified fiscal strategy 4. Service coordination and integration 5. Supportive public policy (USDOJ, 1999)

As a part of the strategic planning process, successful organizations build in short- and long-term goals for understanding and analyzing their roles in leading change in the broader community. This process may take years of continuing analysis, evaluation, and midcourse corrections, but if it is done deliberately and intentionally, it can yield transformational results.

A Case Lesson

As one example, the Community Action Partnership (CAP) is a collection of more than 1,000 agencies nationally that share a commitment to ending pov- erty by promoting self-sufficiency and helping clients make lasting change. They also share a commitment to local solutions for local problems, so they work within their local communities to identify and create solutions that are holistic and crafted to the specific needs of their communities. When one of these partner agencies in Washington State examined these commit- ments more carefully in order to better measure its impact on both the clients served and the local community, it realized that “self-sufficiency” was both an elusive concept and inadequate to describe what its clients needed and wanted. This was further accentuated through recognition of the diverse cultural populations the agency served.

Historically, a key metric for success in moving low-income people out of poverty has been the federal poverty line. This measure was created in the mid-1960s by calculating the amount of money it cost to buy a basic amount of food and then multiplying that amount by three. Each year, the line is updated to account for inflation. However, the causes and solutions of “poverty” are complex and multifaceted and thus require more than a static number that was created more than 50 years ago and that is based on economic circumstances

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and measures that have changed dramatically since that time. Because that threshold is used to determine eligibility for federal, state, and local assistance, understanding what it takes to move clients out of poverty has vast implications for the clients served by CAP agencies. However, given the well- documented limitations of the federal poverty line measurement, a deeper dive into the dynamics of poverty has taken place in the more recent past.

Working from that view, the agency took a closer look at its community and found that within the broad category of poverty, several key learnings emerged that helped it refine and reshape its core programs to more fully address its mission. The first was a result of recognizing how fragile the plat- form of stability is for people living in poverty and how prone to crisis they live on a daily basis. Thus people living in poverty experience ongoing stress and often live with a pervasive sense of hopelessness. Clarifying that perspective, the agency recognized that helping people achieve success in creating even short-term stability with the basic needs of food, shelter, warmth, and safety was a highly important foundation from which its clients could then focus on setting and working toward mid- to longer-term goals to build the personal skills and assets they would need to move permanently out of poverty.

A second area of service developed from the recognition that there is a significant group of people who will never achieve full economic self- sufficiency but who nevertheless can achieve a high level of quality of life, independence, well-being, and self-efficacy. These people might have per- manent physical or mental barriers or simply live on fixed incomes owing to retirement or other situations. Living on a fixed, relatively restricted income often engenders a sense of permanent anxiety. Understanding this enabled the agency to offer services to that segment of its clients with a menu of targeted assistance, focusing on those services that enable consumers in such circum- stances to reduce their reliance on public assistance and also achieve a greater feeling of security, thus realizing an enhanced quality of life in the long term.

A third and critical insight came with the recognition of differences that exist within the broad category of poverty and the resources needed to address these differences. Generational poverty and situational poverty are different, for example. Situational poverty is typically of shorter dura- tion and is caused by circumstance, whereas generational poverty is defined as being in poverty for two or more generations. Where situational poverty can often be addressed in a straightforward manner with various resources, addressing generational poverty is a more complex process (Payne, DeVol, & Smith, 2006, p. 6). Depending on the particular needs of the family, cli- ents living in generational poverty may need access to a variety of resources, which can include financial, emotional, mental, physical, and spiritual resources, as well as support systems and knowledge of middle-class hidden rules and role models (Payne, DeVol, & Smith, 2006, pp. 11–13). Successful poverty-reduction programs have recognized that clients do not need (or want) to be in long-term, highly prescriptive programs with specific steps outlined by agency experts. Agencies recognized that impact occurred when they used more holistic, strengths-based approaches that (a) appreciated the

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complexity of individuals and family units, (b) holistically supported clients’ strengths and resilience and built on both, (c) identified obstacles that clients needed to remove or mitigate, and (d) provided a success platform on which clients were able build the personal skills, assets, and tools they would need to acquire to move successfully—and permanently—out of poverty.

These learnings fundamentally changed the work of the agency. While CAP is a large organization and provides a broad level of services to support clients in their journeys, it quickly recognized that it does not cover all of the life domains in which clients need to be successful. As a result of this work, a burgeoning realization came that in some life domains, service interventions were woefully lacking in the community. “Workarounds” were developed to help clients in the short term, and collaborative community and provider discussions have begun to seek more permanent, systemwide solutions.

Further insight came from a deeper understanding of cultural differ- ences in client groups. While demographic data had long been captured and individual service providers within the agency had always tried to accom- modate the individuality of clients, the realization that basic needs and suc- cess mean different things in different cultures was profound, especially in a community that has become exponentially more diverse in the past decades.

For the agency, two important changes came out of this analysis. First, the role of the case manager was changed from one of urging prescriptive assignments upon client families to one of joining with the clients as collabo- rative coaches. A significant investment was made in training and develop- ing these professionals to help them be consistent and more effective with clients while also enabling the clients to develop and own the behaviors and changes they identified as necessary.

Second, a targeted effort was initiated to identify and develop deeper relationships with other organizations and entities that would be critical partners in a holistic approach to working with clients in the key areas in which they needed specific assistance. While these relationships are not formed quickly or easily, the understanding and clearer communication with partners has the long-term potential to improve client outcomes sig- nificantly. Thus, focused partnerships and coalitions with community mem- bers, government, private businesses, and other nonprofits are increasingly becoming part of the mix to help clients as they make the challenging transi- tion from poverty toward permanent self-sufficiency.

This broad effort was undertaken very intentionally. In its strategic plan- ning process, the agency developed a clear vision of the future that included a goal to improve its effectiveness and the impact of its services on both the clients and the communities served. It also set the stretch goal of dra- matically increasing the number of clients it affected while raising the level of success each achieved. To achieve lasting impact, organizational leaders must be able to observe the larger system at work and create a collective intervention that includes the entire value delivery system, not just the com- ponents in which they engage (Rainey, 2006). While community partners are not always able to predict the detailed outcomes of their collective efforts,

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they can make much better judgments about the direction they and their collaborators need to travel when they can see the larger community goal. Even then, things will likely not happen as they expect, so building a strate- gic process that allows for flexible, rapid, and collective course corrections is important (Burns, 2007, p. 39).

Policy Impact

For many nonprofit organizations, active participation in helping shape public policy may seem daunting and is therefore often prioritized behind internally focused strategy development and execution. This may be because of agencies’ perception that they lack experience in the political arena, as well as the ongoing challenge of providing direct services to their clients with increasingly limited resources. Thus, the tendency is to focus strategy development and execution on internal process improvements, adoption of evidence-based programs, and increased client outcomes, not only because these are so important (to clients served and to funders) but also because they seem more controllable. The demands and “strings” placed on organi- zations by clients, donors, grantors, and others all compete for strategic attention. Many organizations barely have time to just react to everything else, let alone address other issues effectively.

Yet public and social policy changes can be key to true system change; these factors can have the biggest effects on an organization’s success and its ability to effectively achieve its mission. Even in the best of times the sands can shift unexpectedly, but in the current highly volatile world of wild swings in public sentiment and tight government budgets, leaving public policy to unnamed others is a mistake. As a U.S. Justice Department (1999) study suggested, public policy changes are critical to overall systems change success. Thus organizations seeking greater impact must learn how to work with government and advocate for policy change in addition to providing services (Crutchfield & Grant, 2008, p. 6).

It is almost impossible for any single organization to sway the broad opinion of a state legislature or Congress in a meaningful way, and there is no amount of money that can’t be spent in the attempt. And yet the non- profit sector has typically operated using an approach that was geared toward finding a solution within a single organization—what has been called looking for “isolated impact” (Crutchfield & Grant, 2008, p. 38). The secret to success lies in how well organizations can mobilize every sector of society—government, businesses, nonprofits, and the public—to be forces for good. Large-scale social change requires broad cross-sector coordina- tion, not just the isolated intervention of individual organizations (Kania & Kramer, 2011, p. 38).

There are two truths that, at first, seem to contradict each other but that in fact are complementary. The first: In order to have any impact on public policy and systems change, individual nonprofits must employ a

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very narrow focus and specific intent. To do that, advocacy goals must become an integral part of agency strategy. However, the second truth is just as important: Nonprofits must be part of a larger, collective effort across sectors, something in which they have not traditionally engaged (Kania & Kramer, 2011, p. 39).

How? As a first step, organizations must develop as much clarity as pos- sible around the opportunities for and threats to them. Areas of funding concentration and short-term, high-dollar government contracts or grants should be key focus areas. As much as possible should be learned about how those decisions are made and are likely to be made in the future, as well as who the influential decision-makers are. Because this is seldom a core com- petency for nonprofit organizations, determining this may require profes- sional assistance.

Second, the nonprofit must develop a long-term, multipartner strategic initiative to advocate with and for its clients to specifically target the work that will lead to a positive impact on the policies that directly affect the abil- ity to implement successful initiatives. This requires not only broad partici- pation by many of the agency’s stakeholders but also the prioritization of funding for this initiative. The effort can begin with small dollars that can increase over time: For example, in the first year, an organization could fund a consultant to advise it, and then commit some dollars toward a modest lob- bying effort in the following year.

Third, the nonprofit must identify potential partners with interests that align with its own. One local agency partnered with 30 other agencies in its state that had similar missions and created a statewide impact statement and a communal dashboard. The partners also came together to fund a state-level lobbyist who could follow and collectively inform them about the progress of their agenda in the state legislature; these agencies also helped support a national effort to fund a federal-level lobbyist who would inform them of congressional work, the federal legislative agenda, and the ongoing decision-making process. Both the state and federal lobbyists are able to get key information into the hands of decision makers about the important work being done. Because the agencies shared the expense and data-gathering work, the cost to each was modest.

Fourth, know when to supplement the collective effort with individual action. One of the agencies in the partnership described above decided that not all of its key initiatives were being represented by the collective dash- board and the state lobbyist, so it additionally funded a part-time lobbyist to address the unique and specific interests that were critical to its success. This organization carefully coordinated the efforts of the two to ensure maxi- mum impact and avoid duplication of effort.

Fifth, stay focused and choose battles carefully. Once an organization is identified as being “in the game,” it will be called upon to lend support to one side or another of every issue that surfaces. While the sentiment of being a good neighbor is embedded in nonprofit DNA, it is very expen- sive to lobby on everything, and, more importantly, doing so highly dilutes

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Chapter 11 resPonding to PoliCy Change and Creating PoliCy iMPaCt 215

an organization’s influence. Legislators appreciate being approached with a clear and consistent message backed up with data that informs them. Maintain a tight and clearly communicated agenda.

Sixth, use internal resources to augment and optimize the paid lobbyist’s work. An agency’s strategic public policy initiative should include having its CEO, clients, board members, and subject matter experts dedicate time to the effort, be available to testify on important issues to legislative committees, or call on legislators to help them understand key issues from the agency’s perspective and the potential effects of proposed legislation.

Finally, listen to feedback and use it to modify and refine the advocacy strategy and agenda. Many agencies ignore or discount the information they get from their lobbyists because they believe “there’s nothing we can do.” That is not the case. Learning to read patterns in the shifting sands, and then constantly evaluating how an organization’s mission and areas of compe- tence fit into those patterns, can help every entity be more effective in chan- neling resources and energy into programs that provide the most effective outcomes.

One organization reported having been given information that a late- arising but critical amendment, which could have had a huge negative effect on their agency, had been added to a budget request. The agency was able to inform and educate legislators about the issue, even late in the session, and the budget amendment was defeated—averting potential disaster.

For a relatively modest investment in time and resources, an agency can have a significant impact on key elements of legislative agendas that will positively affect its ability to achieve its mission. Further, the information gained about pending legislation, changes in the way funding decisions are made, and opportunities to add incremental value by taking advantage of legislative priorities can and should influence the ongoing evaluation of stra- tegic plans and agendas.

Expanding the reach of nonprofit organizations beyond those we serve to include all who play a role in shaping our community—from makers of public policy and partners throughout the community to those deliv- ering complementary services—is the path to greater effectiveness for the clients we all serve. Doing so with strategic intent and careful planning can dramatically improve the odds of success while providing the bold organi- zation with an opportunity to step to the front to lead these collaborative efforts.

BOYS TOWN’S ROLE IN THE STRATEGIC EFFORT TO REFORM NEBRASKA’S CHILD WELFARE SYSTEM

THROUGH PRIVATIZATION

The following section describes the significant role Boys Town has played in Nebraska’s efforts to improve its child welfare system through privatiza- tion. As a partner in Nebraska Families Collaborative, the remaining private

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Lead Agency the state contracts with, Boys Town has been immersed in the financial, political, programmatic, philosophical, and sometimes emo- tional debate and negotiations that have punctuated the venture, now in its fourth year.

The Need for Reform

Nebraska’s child welfare system was broken. For years, the state had ranked near the bottom nationally in federal Child and Family Services Review (CFSR) measures of safety, permanency, and well-being outcomes for children and near the top in the rate at which it removed children from their homes. In fact, as recently as 2011, Nebraska was removing children from their homes at the second-highest rate in the country (7.9 children per 1,000, more than twice the national average of 3.4 children per 1,000). Caseloads for state caseworkers were above national recommended stand- ards, and families often were forced to navigate an inconsistent, frag- mented, and unfamiliar system. And, like many other states, Nebraska was on a federal performance improvement plan for not achieving its desired outcomes.

Nebraska Gov. Dave Heineman and the director of the Department Health and Human Services decided that Nebraska could better serve its children and families. In 2009, as part of an effort to improve and reform the child welfare system, the Nebraska Department of Health and Human Services (DHHS) finalized contracts with five Lead Agencies that would assume service coordination and service provision responsibilities. (In Nebraska’s privatization effort, a Lead Agency is defined as a private agency—or a collection of private organizations—that contracts with the Department of Health and Human Services to assume responsibility for managing the care and treatment of children and families that are involved with the child wel- fare and/or juvenile justice systems.)

One of those five Lead Agencies was the Nebraska Families Collaborative (NFC). The NFC was created through the formation of a partnership of Boys Town and four other respected local organizations, each with many years of experience serving children and families. Boys Town was instrumental in bringing these organizations together to form an entity that would be able to manage care with quality service provision as its main focus. The other partner organizations are the Child Saving Institute (CSI), Heartland Family Services, the Nebraska Family Support Network, and OMNI Behavioral Health. These organizations were selected because they had years of expe- rience working with Nebraska’s children and families, could provide a comprehensive network of needed services, and together could provide guidance on services needed in the general eastern Nebraska provider com- munity. Also, the NFC Board comprised representatives of service provider organizations.

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Thus, Boys Town entered the world of managing care for children and families, and Nebraska began its often tumultuous journey to improve its child welfare system through a public–private partnership known as privati- zation. The reasons for Boys Town’s direct involvement in Nebraska’s reform effort are numerous and varied.

Historically, Boys Town has always been a direct services provider, offer- ing children and families a wide variety of life-changing services and pro- grams through our Integrated Continuum of Care®. The Integrated Continuum enables Boys Town to link four main categories of care in a research- proven approach that is based on the consistent delivery of the Boys Town Model®.

• Behavioral health care, which includes psychiatric residential, outpa- tient mental health, and substance abuse interventions

• Out-of-home services, which includes foster care and group care • In-home and community-based services, which include the Boys Town

National Hotline®, Common Sense Parenting® classes, and community- and school-based programs

• Health care, which includes physical health care and research and treat- ment of communication disorders in young children

This unique approach enables us to help more children and families in more ways with the same expectations for positive results. For children, this means being successful in school, at home, and on the job while grow- ing into productive citizens. For families, it means having a safe home, being able to solve problems, and staying together. For communities, it means stronger families and neighborhoods and a safer, more productive society.

While Boys Town has taken a leadership role in advocating for change in child care systems, taking on the task of managing care was a big step into uncharted waters. Boys Town had never viewed itself as a manager of ser- vices, and had not seen the required business and financial model as some- thing in which we wanted to be involved. However, Boys Town decided to move forward because we saw the state’s reform effort as the first window of opportunity in recent times to significantly improve the quality of services for children and families in the child welfare system.

Boys Town felt an obligation to actively participate in system reform, because doing so fit well with our advocacy of finding better ways to help children by keeping more families together. Furthermore, taking a leader- ship role in managing care matched well with our strategic plan goal of growing more family- and community-based programs. And the experience of partnering with other organizations and individuals in a collaborative reform initiative would serve us well as we worked with community lead- ers to identify and address the needs of children and families in specific neighborhoods.

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Getting Established

In establishing a framework for its privatization venture, the state of Nebraska set the following goals:

• Improved CFSR outcomes in the areas of safety, permanency, and well-being

• Serving more children in their homes rather than through out-of-home care

• Shared ownership in achievement of outcomes through public–private connections

• A streamlined system for families that reduced or eliminated service gaps

• Greater use of best practices and evidence-based models • Improved continuity of services and stability of placements • Individualized service plans rather than a limited menu of specific

services • Performance-based contracts with incentives and sanctions • Aftercare services and support

To prepare for privatization, Boys Town took a number of steps to estab- lish a solid foundation for creating the Nebraska Families Collaborative.

• First, Boys Town sought to manage liability. Making the NFC a separate 501(c)(3) allowed it to purchase separate insurance and mitigate risks.

• Second, Boys Town selected local partner organizations with a shared vision, quality programs, solid management and staff, services Boys Town didn’t offer, and a wide-ranging capacity to network with provid- ers, funders, and advocates. All of the organizations were experienced and widely respected.

After decisions were made about the best legal structure and partners, Boys Town and its NFC partners turned to learning more about how to make pri- vatization work in Nebraska.

• Boys Town drew on its extensive experience as a service provider in states such as Florida and New York, as well as still others where reform initiatives had been under way for years.

• Boys Town and its NFC partners visited organizations that served as Lead Agencies and sought advice from experts with national reputations in privatization. We learned about the critical elements of developing a successful structure, as well as about the successes and failures other states had experienced.

• Boys Town and its NFC partners conducted a financial analysis, learn- ing that the state’s contract was less than optimal for the following reasons:

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∘ The effort was clearly underfunded. All five original Lead Agencies cautioned the state that funding was insufficient and that some pro- viders would go under. The state maintained its course. As a result, Boys Town and its NFC partners had to financially subsidize NFC’s operations, with Boys Town providing the largest contribution. Boys Town was willing to do this to make sure the window of opportu- nity for real change stayed open and to advocate for high standards and best practices.

∘ For the first 2 years of privatization, the state maintained case man- agement authority, leaving Lead Agencies with little control over children’s entry into and exit from the system or over decisions about children moving back home. This created further financial complications, mainly because the state and other stakeholders were making decisions about the budgets of the Lead Agencies with little or no input from those agencies.

The state contract also called for an increased community-based approach to providing alternatives to out-of-home placements. Network development called for a stronger provider base with increased accountability so it could effectively serve more families through preventive programs.

The NFC was designed to promote the concept of providing “the right service at the right time” for children and families. This mirrored the main goal of Boys Town’s 5-year strategic plan to implement its Integrated Continuum of Care. The NFC would offer both case management and service coordination services that would help children and families stay together, prevent the removal of children to out-of-home placements, and put a greater emphasis on family-focused needs and outcomes. This would improve the continuity of the physical, emotional, and mental health aspects of youth and family well-being. If children were required to receive out-of-home care, NFC would have services and resources in place to maintain progress and provide support once children returned to their families or entered other permanent placements.

Progress and Achievements

When the NFC began providing services, it initially was responsible for one- third of the child welfare cases in the jurisdiction (Eastern Service Area, or ESA) that comprises Nebraska’s two most populous counties. These coun- ties are home to approximately 40% of all of the children and families in the state’s child welfare system. By March 2012, the NFC had assumed case management of 100% of the child welfare cases in the jurisdiction, more than tripling the number of families to which it was providing services. With an effective combination of a stable caseworker and support staff, a variety of innovations that promote family-centered practice, frequent

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family team meetings, and aftercare supports and services, the NFC brought consistency and an outcomes-driven approach to the system in the jurisdiction it served.

A little over a year after NFC assumed full responsibility for all cases in the ESA, there has been significant progress and notable gains in a number of outcome areas. However, we recognize that we have a long way to go. With the support and advocacy of its partner organizations, NFC has stayed the course through numerous challenges and setbacks in order to do what is best for the children and families of Nebraska.

New Approaches

One major accomplishment, thanks to system reform, has been the intro- duction to the state of new child care philosophies and technologies. For example, there is a more conscious effort to work toward providing more adoptive or relative care for children. This effort is backed by a proliferation of in-home and intensive family preservation services and the implementa- tion of evidence-based assessments. For instance, for more than 2 years, NFC strongly advocated adopting the structured decision-making safety model, because the old system was inadequate and allowed too many children to enter the system unnecessarily. The DHHS has adopted this model and now credits it with helping to lower the number of children in care.

Building on the foundation that was established through their earlier work, the NFC’s contributing partners and other community agencies have played a major role in improvements in key areas of child welfare system reform.

Outcome Accomplishments: Reducing State Wards, Increasing Adoptions

In October 2012, the Nebraska DHHS announced a decrease in the number of state wards in Nebraska’s child welfare system. Data results showed a 5% drop from July 2012, resulting in a 12-year low.

The NFC provides case management for 40% of the total child welfare cases statewide. The cases the NFC manages now account for

• 68% of the reduction in total cases statewide • 67% of the reduction in wards in out-of-home care statewide • 55% of the reduction in the total number of state wards

Data from previous years (2009–2011) showed that between 35% and 38% of all adoptions of children in Nebraska’s child welfare system occurred in the Eastern Service Area. Year-end data for 2012 indicate that the ESA accounted for 50% of all the adoptions in the state.

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Process Accomplishments: Greater Staff Stability, Increased Family Interaction, Lower

Caseload Ratios

In accordance with national standards, the NFC is fully staffed and has had little turnover of its family permanency specialists, who are responsible for case management and service coordination. This means that families are able to work with the same specialist and receive consistent guidance, support, encouragement, and care throughout their involvement in the child welfare system. With a full staff, the number of family team meetings will also con- tinue to increase so that families can be more engaged and involved in the care they receive. Caseload numbers are also improving, with more than 70% of family permanency specialists in the ESA assigned to best- practice caseloads of 17 or fewer cases. All of these factors contribute to building stronger, successful families.

CFSR Accomplishments: Improved Safety, Permanency, and Well-being of Children and Families

NFC has made significant improvements in all federal CFSR measures related to safety, permanency, and well-being. In the Eastern Service Area, the NFC has met four measures with scores that are equal to or higher than the state average; in a fifth area, the ESA scored higher than the federal target score.

Community Accomplishments: Positive Consumer Survey Results

In August 2012, NFC conducted the first of its annual consumer surveys to gather input from youth, parents, and stakeholders in the areas of staff pro- fessionalism, the NFC network, community supports and services, barriers, and family-centered practices. The sampling selection included all current NFC-served youth and families and stakeholders.

Parents and youth were asked to rate their satisfaction with services on a 5-point scale, with 1 as “poor” and 5 as “excellent.” Overall, parents and youth said they were satisfied that services had helped their family make positive changes. The average parent rating for overall performance was 3.8, and the average youth rating for overall performance was 3.9. The highest rating from both parents (81%) and youth (80%) was for “being treated with respect.” Stakeholders’ highest rating (97.3%) was for the level of profes- sional skills of NFC staff. (The full consumer survey and executive summary can be viewed at www.nebraskafc.org.)

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Important NFC Milestones

A top achievement for NFC in late 2012 was the endorsement of its work as a Lead Agency by an outside evaluator. Legislative action required an external evaluation of both the DHHS and NFC, and the evaluation was conducted by an independent organization, the Center for the Support of Families of Silver Spring, Maryland. The Center, which has extensive experience with outcome measures and organizational assessment of systems, particularly child wel- fare practices and services, contracted with Hornby Zeller Associates, Inc., to complete the Nebraska review.

Hornby Zeller representatives spent two weeks in Nebraska gathering and reviewing information and interviewing stakeholders, providers, and fami- lies. The top recommendation in their report was for the Eastern Service Area (comprising Nebraska’s two most populous counties) to remain with the NFC to ensure system stability for children and families. This, they said, would keep the focus on meaningful, family-centered reform and the delivery of quality services.

The main point derived from this recommendation is that Nebraska is fol- lowing the right course of action to improve care and services for the state’s children and families. It also means that a private provider such as the NFC can continue to play a critical role in moving the state’s reform efforts forward, and that through a continued collaborative effort involving the DHHS, the legisla- ture, the governor’s office, stakeholders and other agencies, and NFC, Nebraska can raise its child welfare system standards and achieve better outcomes.

In December 2012, NFC received national accreditation from the Council on Accreditation. It was the first time in Nebraska history that a child wel- fare and juvenile justice services case management entity earned national accreditation. Recently, NFC data were transferred from an old informa- tion management system to a new system called FamCare, a flexible, cus- tomizable, web-based case management system that will provide NFC with improved organizational and provider oversight and foster better commu- nication among employees by way of advanced reporting, notification, and operational workflow controls.

NFC currently contracts directly with nearly 50 qualified Nebraska ser- vice providers, capitalizing on their collective excellence in management, best practices, and support systems to help ensure that children and families receive effective services and experience positive results.

Even with all of these significant improvements, system change is very difficult, and as one goal is reached, another obstacle or barrier looms ahead. All is not rosy.

Challenges and Obstacles

The challenges of and obstacles to reforming Nebraska’s child welfare sys- tem have been numerous, complex, and sometimes self-inflicted. A sus- tained collaborative and cooperative relationship between the state, its Lead

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Agencies, and its private service providers was critical to the success of the reform effort. Unfortunately, such relationships have not always been stable or reliable, and it has been difficult to create and maintain steady momentum toward desired goals. Here are some of the main challenges and obstacles that have hindered progress toward positive changes in the child welfare culture and climate:

• There was a significant lack of education on how reform would occur. Despite receiving advice and recommendations from experts on reform efforts in other states, Nebraska moved quickly toward privatization without preparing stakeholders such as judges, legislators, agencies, and families. As a result, there was insufficient consensus-building among key decision-makers regarding the direction and implications of this plan.

• The privatization effort has consistently been underfunded, and there has been an ongoing struggle to procure funding that can adequately cover the costs of providing quality, effective, and individualized services to chil- dren and families. In fact, each of the original five Lead Agencies except the NFC withdrew or terminated its contract because of inadequate fund- ing, leaving the state to take back case management and service provision responsibilities in the four jurisdictions these agencies served. Specifically, one Lead Agency filed for bankruptcy, two gave notice to terminate their roles as Lead Agencies, and the fourth negotiated a settlement to leave. The NFC, with its partnership of Boys Town and the four other local organizations intact, remained as the sole Lead Agency, and continues to negotiate with the state in order to achieve the financial viability and pay- ment system necessary for continuing its Lead Agency role.

In recommendations from its evaluation report on NFC last year, Hornby Zeller Associates stated, “There is no reasonable expectation that the private sector will pick up some of the costs of what is fundamentally a public function. The implication is that the State has to cover the legiti- mate costs of NFC’s operations, if it is to continue with privatization.”

• As other Lead Agencies departed, the NFC assumed responsibility for more cases in the Eastern Service Area. Over a 5-month period, the NFC’s responsibility grew from one-third of all cases to 100% of all cases. This necessitated the hiring of 102 additional staff members and the transi- tion of 1,217 families to NFC-managed services, both of which had to occur very quickly in order to maintain stability and consistency. Such swift, dramatic growth challenged both NFC’s culture and its systems.

• Approximately 1 year after privatization efforts began, the director of the DHHS left and was replaced by a new director. With turnover in this and other key positions, new people with new ideas, new visions, and new priorities for how reform should proceed were added to an already tumultuous situation.

• Political support for privatization has constantly changed over the past several years, especially as some Lead Agencies departed. Some legisla- tors and political figures who initially supported privatization became

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soured over these departures, and the exit of some agencies created significant animosity because they had been delinquent on their pay- ments to providers. Some providers could not keep their doors open without these payments, and provider capacity was lost in some of the most underserved areas of the state. The issue of privatization also has become a major part of legislative activities, with many child welfare system–related bills being introduced during the Nebraska legislature’s two most recent sessions.

• State data systems were not in place to support Lead Agencies. They had to be developed so that there could be measures to determine if accept- able standards were being met and whether children and families were receiving quality services in a timely manner.

Lessons From Boys Town’s Venture Into System Reform: What We Learned, How We Changed

Boys Town and the NFC have faced many challenges and obstacles since pri- vatization began. But Boys Town and its NFC partner organizations have been unwavering in their support of continuing privatization as a viable reform approach. This support has remained firm because it is based on a commit- ment to doing what is best for the children and families of Nebraska. System reform created a window of opportunity for providing improved services for children and families that were not previously available in Nebraska. This window needed to be kept open long enough to assess progress and to build on the solid foundation that had been established.

We also have thrived because we were well prepared for the job. With a partnership involving five experienced local organizations, each with a well- qualified workforce and substantial private funding, the NFC was and is today the model of a Lead Agency that can work collaboratively with the state, its local provider network, and other stakeholders for true system reform. Consumers such as families, the judiciary, many legislators, and child advocates acknowledge system improvement.

The overriding purpose of any system reform effort must be to ensure the safety, permanency, and well-being of the children and families being served. Collaboratively finding ways to provide the best services possible in ways that prevent or reduce trauma, instill confidence, and result in positive outcomes should supersede pointless squabbles that are politically, finan- cially, or personality driven.

Lesson 1: Solid strategic planning is critical to the success of any system reform effort. A clear direction and a concrete plan must be developed by those in charge of system reform far in advance of reform rollout and must include input from all involved agencies and stakehold- ers as well as those who will be indirectly affected by implementation of the plan. Planning should look at every element that will be necessary for

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success, from organization, staffing, and finances to decision making, vision, and capacity building. Even though contributors bring different ideas and resources to the table, everyone eventually must be on the same page when it comes to goals, processes, outcomes, and responsibilities.

In addition to having a viable plan for system reform, it also must be possible to implement and sustain the plan over time in order to accomplish short- and long-term goals. For the state of Nebraska, 3 years was barely enough time to implement such enormous change, particularly with the fail- ure of Lead Agencies and the subsequent acquisition of more families and territory by Nebraska Families Collaborative, the remaining Lead Agency. There must be an understanding that turning a very large ship in a different direction requires patience and endurance.

Lesson 2: It takes a potent, established organization with a developed infrastructure to take on the task of managing care. The fact that Boys Town had financial stability, IT resources, human resources expertise and experience, and other important strengths such as insur- ance coverage and national accreditation enabled us to weather the storms of uncertainty, doubt, and outright confusion that plagued Nebraska’s reform effort.

Even with all of the essential elements in place, Boys Town encountered challenges, most significantly with financing and budget issues. For exam- ple, we learned that if planning needs weren’t completed before the state established its fiscal year budget or if changes were necessary during the budget year, no significant revisions could be made until the state’s next budget cycle.

Lesson 3: Dealing with the complexities of multiple systems is a major challenge to reform success. As a service provider, Boys Town has always understood our responsibilities to our stakeholders. But our stakeholders had always been children and families—the recipients of our services.

Direct involvement in managing care for thousands of families meant dealing with and assuming new responsibilities with a much larger pop- ulation of stakeholders—state officials, legislators, judges, county attor- neys, other child and family care agencies, child and family advocates, and others—as well as entering the political decision-making arena. Decisions that were being made, sometimes with our input and sometimes without, affected the people of entire communities and counties, and Boys Town had to learn how to build alliances with many diverse participants in the child welfare system.

Even with our experience in working with others in the child and fam- ily care field for many years, Boys Town had to learn how to do things much differently and to revamp its negotiation, compromise, and advocacy skills.

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One major positive outcome of the NFC partnership and its involvement in multiple systems was that Boys Town and other providers increased their advocacy efforts and political engagement with the state by working closely with legislators, the DHHS, and the governor. Boys Town has much greater access to decision-makers and stakeholders at the top levels of state govern- ment and has forged relationships that promote a better understanding of the child welfare challenges Nebraska faces and the best ways to address them. Agencies have worked together like never before and are continually seeking partnership opportunities to create innovation.

Lesson 4: Leadership and hard work do pay off. Despite the struggles and pitfalls, the Nebraska child welfare system is better than it was before reform efforts started, and more children and families are getting the right help in the right way. There has been little financial or political gain, and little media or public fanfare, but consumers are telling us their lives are bet- ter because of the services they now receive. Services and care management have improved, and fewer children are experiencing the trauma of being removed from their homes. Falling back on the mission to save children and heal families is never more important than when it appears there are no con- crete rewards on which to rely. Solid, determined leadership is essential to keeping staff and organizations on course.

Lesson 5: Many people want to reform the child welfare system for the right reasons, but bureaucratic processes make it difficult to achieve significant progress. Boys Town has developed relation- ships with many state, agency, and care provider staff members who are committed to making a positive difference in the lives of children and families in need. Their motives are altruistic and they are dedicated to bringing about real change. Unfortunately, Boys Town has learned that its own bureaucracy, along with those of the state and the general pro- vider system, and the restrictions under which they operate, can stymie progress just as easily as it can make it possible. Any organization that gets involved in child welfare system reform must be aware of the gaunt- let of obstacles that has to be negotiated in order to accomplish even the simplest goal.

Lesson 6: Discouraging accounts of reform mistakes reported in the research and the experiences of those in other states who trod the same path of reform Nebraska is traveling now are more than warnings—they are replicable realities. Because private providers are state-funded businesses, even the most well-intentioned state leaders can stumble into the pitfalls of underfunding, moving too quickly, inadequate planning, and lack of education for stakeholders. Boys Town was told about these pitfalls, read about them, tried to listen, and tried to educate the state

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about them. Yet Boys Town, its NFC partners, and the state all fell prey to many of the mistakes of the past. The lesson here is that being aware of the worst things that can happen is no insurance against the worst things hap- pening again. It’s best to plan for the worst and to stay focused on the prize: ensuring the safety, permanency, and well-being of children and families in need.

It’s no accident that the NFC partnership is the remaining Lead Agency in Nebraska’s reform effort. From the start, the NFC had the support, infra- structure, staffing, funding and business models, and committed network of local child care providers with experience and expertise in child and family care necessary to make system reform a success. The NFC’s contributions are helping to drive down the number of children in the state’s care and provide additional services to meet more of the needs of children and families while actually increasing the number of families that receive services. (In each state where reform has been attempted, an enhanced network of services has been critical to success.)

Lesson 7: Change is the only certainty! Nebraska’s effort to privatize the provision and coordination of services for children and families gener- ated changes that rippled through every aspect of the child welfare and juve- nile justice systems, and the agencies and organizations that were involved. There were leadership changes, funding changes, changes in the scope of services, changes in how everyone did business, and changes in the dynam- ics of control and decision making, to name a few. These changes demanded flexibility and open-mindedness on the part of the NFC and its partner organizations. Resisting or not adapting to any of these changes would lead to self-implosion and end the venture.

At the NFC’s partner organizations, including Boys Town, senior man- agement had to take a leadership role in convincing their respective boards that privatization could and would work, and that despite the challenges and changes everyone faced, moving forward would result in better care and ser- vices for the children and families of Nebraska. For Boys Town, this meant falling back on our mission as the motivation for accepting and implement- ing the changes that were necessary for success. Without our mission and its focus on the betterment of the child and family care system, the required changes would not have been worth making.

While the NFC’s status remains somewhat tenuous in the future big picture of reform and there is still much more to learn, significant improvements have been achieved in services, programs, systems, and man- agement of the needs of Nebraska’s children and families.

We don’t know what the future holds for privatization and continued efforts to reform Nebraska’s child welfare system. But Boys Town and its NFC partners remain committed to advocating in the best interests of chil- dren and families, simply because it’s the right thing to do.

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INNOVATION AT THE PHILADELPHIA DEPARTMENT OF HUMAN SERVICES: IMPROVING OUTCOMES FOR CHILDREN BY INCREASING ACCOUNTABILITY AND STRENGTHENING

COMMUNITY PARTNERSHIPS

Summary

The old African proverb “It takes a village to raise a child” is one that the Philadelphia Department of Human Services (DHS) has come to embrace. The latest in a series of reforms at the agency is a new initiative called Improving Outcomes for Children (IOC), which aims to improve service delivery and outcomes for children in care by engaging community partners, streamlining case management, and vigilantly tracking outcomes indicators to measure the initiative’s success. With this initiative, the Philadelphia DHS is embrac- ing a new model of child welfare that acknowledges that public agencies cannot singlehandedly combat child abuse and neglect, but rather that com- munities are in the best position to help protect children and support fami- lies during times of need. By engaging these communities more effectively and recognizing their essential, if informal, roles in service delivery, and by using data to measure success, DHS believes it can improve the safety, per- manency, and well-being of the children in its care. The Philadelphia DHS is not the first agency to experiment with this hypothesis of change, but given the particular challenges they face, if they are successful, there is enormous potential to influence child welfare agencies nationwide by changing prac- tices and the mindset of child welfare service delivery.

The Issue: The State of Child Welfare in Philadelphia

The federal government charges states and localities with ensuring the “safety, permanency, and well-being” of all children who may be at risk for child abuse or neglect (Adoption and Safe Families Act of 1997). To meet these mandates, child welfare agencies investigate reports of alleged child abuse and neglect, provide services to the families, or, if the child’s safety is determined to be at risk, remove children to foster family homes, the homes of screened relatives, or group homes. At any given time, roughly 400,000 children are living in foster care (Department of Health and Human Services, 2012).

Although the federal government sets the national standards for the services states must provide through their child welfare systems, states and local jurisdictions are charged with implementing these ser- vices in ways that best meet the needs of their individual communities. Pennsylvania’s system is county-based, with all 67 county child welfare agencies in the state overseen by the Pennsylvania Department of Public Welfare. The Philadelphia DHS is the largest child welfare agency in the

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state and among the largest in the country. Philadelphia handles both dependent and delinquent children as well as families provided with in- home court-ordered or voluntary prevention services. However, unlike most other systems, Philadelphia also places children into the system for truancy, introducing into the system a population of children not normally seen by these agencies.

In FY 2011, on a budget of approximately $600 million, DHS served a total of 11,330 children in dependent and delinquent placement settings as well as 60,000 youth and 20,000 families through nonplacement in-home services, both court-ordered and voluntary (Philadelphia Department of Human Services, 2012). Like so many other agencies, the DHS has also suffered system breakdowns leading to tragedy. In early August 2006, an ambulance was called to the home of the family of a DHS client named Danieal Kelly to find the 14-year-old girl lifeless, weighing only 46 pounds, and with weeks-old bedsores covering her body from gross neglect. Most horrifying was that her family had been receiving services from the DHS for years, and was supposed to be receiving biweekly visits from a caseworker through a private provider with whom DHS was con- tracting. Like other children before her, Danieal fell through the cracks of the system.

In the aftermath of the incident, then-mayor John F. Street appointed a group of national and local child welfare experts to a community over- sight board (COB) to systematically investigate what led to Danieal’s death and make reform recommendations. In its first report, in 2007, the COB focused many of its recommendations on safety, which the panel identified as the primary and essential role of child welfare departments. To help ensure safety for children in care, the COB recommended that the DHS implement an appropriate safety assessment tool to more accurately assess a child’s safety and risk in different placement settings, increase the num- ber of face-to-face contacts required between caseworkers and children, and implement an intensive team decision-making process for all young children in care.

The COB also recommended that the agency improve its performance monitoring to track the outcomes of children served, measure the impact of policy changes, and identify areas needing improvement. This included enhanced oversight of the provider agencies under contract with the DHS, including linking outcomes to financial incentives for the agencies. Responding to this recommendation, Commissioner Anne Marie Ambrose created the Division for Performance Management and Accountability (PMA). She further emphasized the importance of monitoring by recruiting a deputy commissioner to staff the new division and implement processes for rigorous quality assurance. Although the federal government requires states to report basic statistics related to safety, permanency, and well-being, for the first time the DHS began to use these statistics to describe its own performance.

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In creating the new division, the DHS made an important distinc- tion in social sector management between outcomes and indicators. An outcome, as nonprofit consultant David Hunter argues, is “an endur- ing change in something about which the organization cares deeply.” The DHS’s primary outcomes are safety, permanency, and well-being. Indicators are “concrete and measurable things that an organization will look at to assess whether it has succeeded in reaching a given outcome” (Hunter, 2006). A decrease in the number of incidents of child abuse and neglect while receiving services, for example, is an indicator of safety; an increase in the number of children exiting foster care to a permanent placement (i.e., adoption or reunification with birth family) is an indicator for permanency; increased rates of school attendance are an indicator for child well-being.

This new focus on outcomes and accountability is also exemplified by the successful, though difficult, implementation of a performance-based con- tracting (PBC) system in which all provider agencies contracting with the DHS are held to strict performance standards, including permanency indi- cators and placement stability (City of Philadelphia Department of Human Services, 2011). Initially this system applied to general foster care agencies only, but it has since been expanded to apply to treatment foster care and in-home protective services. In 2009, DHS began publishing annual rankings of these providers, with the expectation that if the agencies did not perform well, the DHS would no longer offer them the contracts. This type of trans- parency was an enormous step towards increasing accountability within an agency that had operated for years without it. Concrete outcomes are now the norm by which provider agencies in Philadelphia serve. Although it was a difficult reform process for both the agency and its provider partners, PBC has positively affected the quality of care provided to DHS-involved fam- ilies. By holding itself and provider agencies accountable to continuously monitored outcomes and indicators, the DHS has achieved permanency for thousands more children.

The challenge for all child welfare agencies is to ensure that no child falls through the cracks. The DHS has completed the majority of the reforms the COB recommended, including a host of other reform initiatives not men- tioned above, in furtherance of the three-part aim of safety, permanency, and well-being. The agency is committed to seeing through the COB’s recom- mendations and its new policies and initiatives to keep Philadelphia’s chil- dren safe and protected.

The Problem: The Challenge of Keeping Children Safe

Despite the thousands of children DHS does keep safe every year, and the enormous improvements that have been made since Danieal’s death, some children remain at risk. The DHS, of course, wants to ensure that

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all children remain safe under their care, and both agency and city lead- ers continue to make that a primary goal for the agency. Mayor Michael Nutter has made reforming the DHS a priority during his tenure and, like Mayor Street, has relied heavily on the COB’s recommendations as a force for reforming the city’s child welfare department. Mayor Nutter also appointed Commissioner Anne Marie Ambrose, a child welfare and juve- nile justice systems veteran with a record of reform, to take the reforms at the DHS even further.

Under Commissioner Ambrose’s leadership, the agency has made impressive and measurable progress. She has devoted significantly more resources to the newly developed PMA division of the DHS, allowing for a more serious focus on data collection and tracking and giving the divi- sion more muscle within the agency to create change. Since her appoint- ment in June 2008, she has also decreased the number of children in foster care by 33%, decreased the number of out-of-state placements by 79% for dependent youth and 91% for delinquent youth, and increased the number of children leaving foster care for permanent placement by 12% (Philadelphia Department of Human Services, 2012). The Philadelphia Inquirer editorial board, a harsh critic of the DHS in the past, noted this progress 3 years after Commissioner Ambrose’s appointment: “Important reforms have been made within DHS, with more to come. That means bet- ter protection for vulnerable children” (Philadelphia Inquirer Editorial Board, 2011).

One of the most difficult of the COB recommendations left for the DHS and Commissioner Ambrose to address was the problem, caused by a dual case-management system, of the lack of clarity regarding the responsibili- ties of DHS caseworkers versus provider agency caseworkers. To families and foster parents, dual case management can feel like a rotating door: Families don’t always know which caseworker will be visiting their home, which one to contact, and who will be with them in court. Importantly, and as illustrated by the Danieal Kelly tragedy, dual case management doesn’t allow for clear accountability. The Philadelphia DHS is one of the largest child welfare systems in the nation that gives case management responsi- bilities to both DHS workers and provider agency caseworkers, and it has become clear that this duplication of roles could be eliminated with more clarity and structure between the agency and providers. With this in mind, the DHS decided on a bold innovation, moving from the current dual case- management system to a more streamlined model to improve the quality of services provided to families. On its face, this recommendation seems like better management through simplification, but within an agency as complex as the DHS, making it happen has proved daunting. The new initiative is appropriately named Improving Outcomes for Children, and the COB will oversee its implementation.

The COB also recommended that the DHS strengthen community part- nerships to encourage community participation and input in DHS practices

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232 Making strategy Count in the health and huMan serviCes seCtor

and improve continuity of care. This recommendation is based on a few model programs nationwide that have demonstrated that effectively engag- ing community partners can greatly improve outcomes for children and families (Center for the Study of Social Policy, 2011). Although the DHS has partnered with more formal organizations providing supports such as legal aid, health care, and social services, they have yet to engage more informal supports such as faith-based organizations and community members in areas that touch the child welfare system the most. By not working alongside such partners, the DHS is often viewed as an enemy by many communities, and fails to tap into networks that could help them stabilize families to keep vulnerable children safe.

To tackle these remaining challenges, the DHS turned to Casey Family Programs (CFP), which has been supporting the agency’s reform efforts since 2006. CFP is a highly regarded national foundation established by UPS founder Jim Casey in 1966. Since its inception, CFP has worked with count- less child welfare agencies across the country to improve their practices based on the best knowledge in the field.

The Solution: Improving Outcomes for Children

With the help of CFP, the DHS began exploration of the new IOC initiative in November 2008 by visiting New York City, looking at Commissioner John Mattingly’s IOC initiative, and conducting a comprehensive review of initiatives around the country that have created a single case-manage- ment system and effectively engaged community partners. After studying several individual reform models, the DHS ultimately decided to design its own model based on similar initiatives in Florida and New York City, both of which, like Philadelphia, rely heavily on provider agencies for day-to-day case management. The DHS believes that its new IOC model will be transformative for the agency and will do more to improve out- comes for all children and families in the system than any prior agency initiative. It is indeed the most ambitious of any of the DHS’s reform efforts to date.

The research in child welfare is clear that children do best when they remain in families, preferably their own families, whenever possible (Doyle, 2007). Emerging successful initiatives have shown that families, particularly families most at risk of coming to the attention of the child welfare system, need strong communities to support them, and that pub- lic child welfare agencies must partner with members of those commu- nities to effectively ensure the safety and well-being of at-risk children. The theory holds that by engaging members of a community, making them aware of how the child welfare system affects their community, and empowering them to intervene with a family who may be struggling, neighborhoods may recapture a sense of responsibility for the welfare of

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Chapter 11 resPonding to PoliCy Change and Creating PoliCy iMPaCt 233

their children. This engagement helps protect vulnerable children by sup- porting families before child abuse and neglect occur in the first place, in turn thus preventing some families from even coming to the attention of the DHS.

Achieving this new community partnership approach will rely on a streamlined case-management system and on strengthening the level of per- formance monitoring and accountability at the agency to track in precise terms the outcomes of this initiative:

If the DHS partners with communities through a streamlined case-management system and clearly defines and tracks relevant outcomes and indicators, holding staff and providers accountable to these indicators, then Philadelphia children will remain safer, find permanent homes, and experience greater well-being.

Single case

management Community engagement

Data monitoring

Improved outcomes for

children

The DHS will measure the success of its programs, including IOC, based on a number of key child welfare indicators it believes can be substantially improved through the IOC initiative. Though the DHS uses many more indicators to assess its overall performance, the IOC indicators do touch all aspects of the three essential goals of child welfare agencies:

Safety

• Decreased rates of abuse • Fewer initial placements • Decreased rates of abuse and neglect occurring in care • Decreased rates of children returning to care (reentry)

Permanency

• More discharges to reunification (biological or kinship family), adop- tion, or permanent legal custody

• Decreased length of stay in care • Fewer movements between placements while in care

Well-being

• Fewer children in group homes and institutional placements

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234 Making strategy Count in the health and huMan serviCes seCtor

• More sibling placements and connections over the life of a case • Decreased racial disproportionality

Throughout the design and implementation process, the agency has relied heavily on the voices of the children and families they serve, com- munity residents, stakeholders, provider agencies, and the DHS staff to inform the development of the model. The DHS believes that its for- mal system of care can be made better by involving informal systems of care as well, including faith-based groups and other community members and stakeholders who may not have otherwise recognized the degree to which they can play a role in supporting the families in their neighborhoods.

The new case-management system model eliminates duplication and clearly delineates roles and responsibilities. Providers, called Community Umbrella Agencies, or CUAs, will be responsible and accountable for ongo- ing case management and day-to-day service delivery, while the DHS’s role will focus on providing guidance and technical support. What makes the CUAs’ role unique, as compared with the traditional role of private providers, is their focus on a specific region of the city: according to the DHS, the CUAs “will ensure that local solutions and resources are more accessible to chil- dren and families” and “develop connections to formal and informal neigh- borhood networks that can strengthen and stabilize families” (Philadelphia Department of Human Services, 2013b).

To facilitate this community engagement, the DHS used geographic information systems (GIS) to map the neighborhoods with the highest DHS involvement and met with stakeholders in those areas to explore how the entire community could work alongside the DHS to support the families. The DHS’s mapping technology also gave the agency more infor- mation about where children go once they are placed in foster care, infor- mation that community members would have had no way of knowing before. Taking children out of their homes and neighborhoods entirely can be detrimental for communities. It also does not foster well-being for children in care: Taking youth out of their communities can have the unintended effect of disconnecting children from their neighborhoods entirely, disrupting their schooling and friendships and discouraging reunification with family. Keeping children within their own communi- ties by encouraging community support networks to promote child safety is thus a desirable goal for the children, their families, their communities, and the child welfare system as a whole.

The implementation phase of IOC began in January 2012, with the DHS focusing first on areas with the highest system involvement before moving to other areas of the city. In March 2012, the department released requests for proposals (RFPs) for the two initial CUAs. The proposed roll- out of IOC, in order of the CUAs with the highest level of need, is shown in Table 11.1.

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Chapter 11 resPonding to PoliCy Change and Creating PoliCy iMPaCt 235

The Innovation: Performance Accountability and Community Partnership

The innovation in the IOC initiative is twofold. First, the data-tracking component of IOC represents the latest, and boldest ever, step towards real and meaningful accountability within the DHS. The initiative is results- oriented, making everyone single-mindedly focused on quality service delivery and improving clients’ outcomes. Accountability done well— using outcomes to assess the impact of programs and policies—leads to improved client outcomes. Although accountability is not a new concept in child welfare, and some agencies nationally have embraced it, most still have not. If Philadelphia can make its system more transparent and accountable, it could serve as an important model for similar jurisdictions around the country.

The second true innovation in IOC is the community partnership com- ponent. The premise is fairly intuitive: Children belong in families, fami- lies operate in a sphere of communities, and most often the reason families enter the child welfare system is that they are isolated from these commu- nities and have nowhere to turn during times of need. If families are well- supported and have access to the resources they need during times of crisis, then children will do better too.

In some ways, enhancing community partnership can be best described as building a continuum of care for at-risk children and families. The model acknowledges that many of the children who touch the child welfare system come from broken communities and are the children of yesterday’s at-risk children from similarly broken communities, or even of the child welfare system itself. By working to establish a continuum of care that can catch

TABLE 11.1 Proposed Rollout of IOC

Planned date for RFP process

Planned date for receiving in-home referrals

Planned date for receiving placement referrals

Planned full implementation

CUA 1 April 2012 January 2013 April 2013 December 2013 CUA 2 April 2012 April 2013 July 2013 March 2014 CUA 3 December 2012 October 2013 January 2014 September 2014 CUA 4 December 2012 April 2014 July 2014 March 2015 CUA 5 July 2013 April 2014 July 2014 March 2015 CUA 6 July 2013 July 2014 October 2014 June 2015 CUA 7 July 2013 July 2014 October 2014 June 2015 CUA 8 July 2013 January 2015 April 2015 December 2015 CUA 9 July 2013 January 2015 April 2015 December 2015 CUA 10 July 2013 January 2015 April 2015 December 2015

Adapted from the DHS IOC Implementation Plan (Philadelphia Department of Human Services, 2013a).

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236 Making strategy Count in the health and huMan serviCes seCtor

families when they need support, and acknowledging that the DHS cannot perform this task alone, the DHS may be able to significantly reduce case- loads and improve outcomes for all children at risk of entering the child welfare system in Philadelphia.

These reforms are particularly innovative and meaningful given cer- tain restrictions in federal child welfare financing. A gaping flaw in the federal funding structure is the inflexibility of Title IV-E (Title IV, Subpart E of the Social Security Act) and its limitations in reimbursing certain ser- vices. Though the legislation accounts for the majority of the money spent on child welfare services, states may only be reimbursed for foster care services; funding from Title IV-E cannot be used for prevention services or other wraparound services to support families in other ways, which could prevent the need for children to enter foster care in the first place. The IOC approach is twofold: supporting a state request to the federal government for a Title IV-E waiver and leveraging community resources to provide these up- front prevention and wraparound supports in a community context. With no stigma of a DHS worker coming to the family home, the DHS may be able to improve overall service delivery even within the confines of restrictive funding sources.

Barriers to Implementation

There are, of course, a number of potential barriers to successful implemen- tation that the DHS faces in the months to come. Chief among these is stake- holder buy-in. A unique feature of the child welfare system is that it involves multiple decision-makers: a typical child welfare case includes not only the DHS but also Family Court and the presiding judge, parent advocates, child advocates, family advocates, provider agency caseworkers, and the city itself through its policies. All of these constituencies are major stakeholders who must become partners in the IOC initiative, and this type of collaboration can be problematic. For IOC to be successful, the DHS must bring all stake- holders to a place where they can find something to agree on. To the extent that IOC is seen as a threat to key constituencies, the success of the initiative will be difficult.

As is often the case in Philadelphia, unions are a huge DHS stake- holder in IOC. Because changes in job descriptions and responsibilities will be required under the new single case management model, the DHS must continue to work with both caseworker and supervisor unions in order to facilitate a smooth transition to the new system. To be sure, being a child welfare caseworker is one of the most taxing jobs in any child welfare agency, sometimes leading to high turnover rates and poor case management conti- nuity for families. The DHS has therefore made a concerted effort to bring caseworkers to the table, to reassure workers that their jobs are secure and that although their work may change, their workloads will not increase. DHS workers will continue to provide a valuable service under IOC.

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Chapter 11 resPonding to PoliCy Change and Creating PoliCy iMPaCt 237

Another key stakeholder constituency is the provider community, whose perspective can get lost in discussions about increasing accountability. Under the new single case-management system, provider agencies, in many ways the heart of the Philadelphia child welfare system, will be perform- ing all of the day-to-day casework. Reforms of the magnitude of the IOC initiative will require significant changes to the provider agencies them- selves, and must take into account the capacity of the agencies to work through these changes. They are truly partners with the DHS in this reform endeavor.

DHS leadership firmly believes that they have and will continue to over- come these inevitable buy-in challenges. They view all these stakeholders as partners in the process with an important perspective to bring to the table. And, given the headway the agency has made in implementing IOC, it is clear that they have been successful in getting much of the buy-in they need. The collaboration of all stakeholders has been key to the implementation process thus far.

Financial Costs and Potential Savings

For the vast majority of children, simply entering the child welfare system puts them on an unstable path. A major goal of IOC is to reduce the number of children in residential and foster placements and to instead keep them within their own families and kinship supports whenever possible. It also turns out that the most restrictive settings, specifically residential and fam- ily foster care, are the most expensive. The average monthly cost of different levels of placement is shown below:

• Approximate monthly cost of family foster care per child = $1,800 • Approximate monthly cost of residential care per child = $3,900 • Approximate monthly cost of kinship care per child = $1,450

If the DHS is successful in reducing the number of children in foster and residential care placements, and if it can prevent the need for children to enter out-of-home care in the first place, it will not only improve child welfare outcomes but also reduce the DHS’s costs substantially. It is a true win–win scenario.

The challenge, now and in the future, is working within the current funding structure to make these changes. Because the primary child welfare funding stream will reimburse child welfare dollars only for out-of-home care, the DHS must learn to be creative with the money available—the agency could lose this needed reimbursement money for good if it is too successful at reducing the number of children in out-of-home care, money that neither the state nor the city governments will be able to compensate for in today’s budgetary conditions.

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238 Making strategy Count in the health and huMan serviCes seCtor

On the other hand, involving informal networks of support within com- munities that may be available to families can help the DHS do a better job taking care of the families it serves without having to pay them to do it. To the extent that the DHS is successful in its goal of connecting families with community supports that already exist, it may be able to make up for the potential lack of resources.

Finally, streamlining case management means decreased duplication and more efficiency in their processes. Though the DHS does not yet have an esti- mate for the financial savings that could result from this increased efficiency, and though Commissioner Ambrose insists that DHS workers will not lose their jobs as a result of the initiative, eventually savings are likely to be substantial, and could free up resources to be invested in community prevention programs.

Policy and Practice Implications: Will It Work?

In many ways, Philadelphia is acting as a pilot site to test the hypothesis that all components of the IOC initiative—community partnerships, single case management, rigorous data tracking, and system accountability for articulated outcomes—will in fact lead to improved outcomes for children. Commissioner Ambrose envisions the DHS becoming a leading child welfare agency in the nation. If she succeeds in this goal, as she has in many others, Philadelphia will become a model for child welfare system reform in other cities nationwide. This is particularly true given the oversight of the COB and the involvement and strong support of Casey Family Programs in IOC.

Although the changes required to fully implement IOC will happen over several years, and progress may seem slow at times, the DHS believes that through this process people will come to realize that they are sincere when they say will become a more transparent system. Their job in the meantime, and in the near future, is to help people see that there isn’t a hidden agenda in this initiative, nor is it just another reform initiative that everyone will forget about in a few years. The Philadelphia DHS believes that IOC, like the PBC sys- tem, will stand the tests of time and of leadership change. According to a mem- ber of the IOC implementation team, although the initiative is a big challenge, the DHS would not be engaging in this enormous effort if they didn’t believe it could achieve concrete and meaningful outcomes for the children they serve.

Clearly, whether these efforts succeed will have enormous implications for the field of child welfare. Any lessons learned from this project will inform other child welfare agencies as they consider future reforms. The child wel- fare field will surely be watching the Philadelphia DHS with interest.

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Center for the Study of Social Policy. (2011). Community partnerships for the pro- tection of children. Retrieved from http://www.cssp.org/reform/child-welfare/ community-partnerships-for-the-protection-of-children.

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