1. Service Coordination in the Department of Social and Health Services A Presentation of the Briefing Report Joint Legislative Audit and Review Committee June 26, 2006 Presented by John Woolley, JLARC Staff

2. JLARC's Analysis of DSHS Service Coordination  JLARC directed analysis  Look for answers to four questions: 1.Current efforts at coordination? 2.Initiatives to improve information systems? 3.Feedback from clients? 4.Other states’ experiences?  A “ lessons learned ” approach Background/ContextBackground/Context Report pages 1-3 Analysis of Service Coordination in DSHS 2

3. JLARC's Analysis of DSHS Service Coordination A Number of Lessons Learned 1. Current efforts at coordination? 2. Improve computer systems? 4. Experiences of other states? 3. Feedback from clients? Initiatives take many different forms— involve just parts of DSHS or involve many participants outside of DSHS; and important to understand what is expected of an initiative. Recent changes in information technology—an emphasis on enterprise-wide information and “hub” strategies—can facilitate information exchange and reduce information redundancy. Client satisfaction surveys in place, but improvements needed to be more accurate. Look at service coordination not as a single event fixed in time, but rather as an ongoing, continuous evolution. Background/ContextBackground/Context 3

4. 4

5. JLARC's Analysis of DSHS Service Coordination  Single largest agency budget: $8.5 billion per year, with 18,000 employees  2.1 million clients equals 1/3 of state’s population—many get packages of services DSHS Provides Services to 2.1 Million Clients Background/ContextBackground/Context Report pages 1-3 Data Source: DSHS Research and Data Analysis, Client Service Database for state fiscal year 2004 Three Services: 171,808 clients, 8% Four or More Services: 48,905 clients, 2% Two Services: 674,556 clients, 32% One Service: 1,201,872 clients, 58% 5

6. JLARC's Analysis of DSHS Service Coordination Information Also Available on Clients’ Use of Multiple Services 1/3 of Aging and Adult Service Clients get some Economic Services Background/ContextBackground/Context Report pages 1-3 Data Source: DSHS Research and Data Analysis: Fiscal Year 2003 6

7. JLARC's Analysis of DSHS Service Coordination  Answering Question 1 learned:  No Wrong Door has “morphed”: no longer stand alone project  DSHS: coordination now part of ongoing strategic planning  Looked at strategic plan and individual initiatives Question OneQuestion One Report pages 5-9 Variety of Current Initiatives Considered Service Coordination 7

8. JLARC's Analysis of DSHS Service Coordination  With 10 separate goals, no specific goal calls out “Improve Service Coordination”  But detailed strategies specifically address boundary crossing issues Question OneQuestion One Strategic Plan—Strategies Cross Organizational Boundaries Goal F: Use Effective Treatment to Enhance Outcomes Objective 2: Standardize practice of early screening, assessment, and referral to services Strategy: Collaborate with other programs serving children, youth and adults to screen for co-occurring mental and substance abuse disorders and link with integrated treatment—includes: Health and Recovery Services, Aging and Disabilities, Children’s, Juvenile Rehabilitation Performance Measure: Increase of consumers receiving an integrated mental health and substance abuse screen—Health and Recovery Services Report pages 5-9 8

9. JLARC's Analysis of DSHS Service Coordination Initiatives Seek Solutions to a Variety of Coordination Problems A-TeamsCollaborative case management for clients to maintain community placement. MH, DD, SA, DOC, AAA, RSN, local law enforcement Children’s Mental Health Initiative Coordinate provision of MH services to children, with possible future goal of consolidation. Children’s and Health and Recovery. Functional Family Therapy Family-based service engaging entire family, with a focus on reducing repeated criminal behavior. Juvenile Rehabilitation and County Juvenile Courts. (evidence-based practice) Report pages 5-9 9 Question OneQuestion One

10. JLARC's Analysis of DSHS Service Coordination Many Initiatives With Diverse Expectations Basic Highly Developed Highly Developed COMMUNICATION - exchange information COOPERATION - work together COORDINATION - systematically align efforts COLLABORATION - joint work effort and product CONSOLIDATION - one system INTEGRATION - bring all parts together Question OneQuestion One Service coordination takes many different forms—it can involve just parts of DSHS or involve many participants outside of DSHS. Importance of understanding what is expected by an initiative: some are geared towards increased communication; some are geared towards the coordination of services; some are geared towards service consolidation, and many are a combination. Report pages 5-9 10

11. JLARC's Analysis of DSHS Service Coordination Coordination of Client Information Historically a Problem  Looked at efforts at improving information coordination.  From simple information (name, address, etc.) to more complex information (assessments, services needed, services provided)  Efforts at eliminating “silos” Question TwoQuestion Two Report pages 11-14 11

12. JLARC's Analysis of DSHS Service Coordination New Technologies May Help Coordinate Information Recent changes in information technology—an emphasis on enterprise-wide information and “hub” strategies—can facilitate information exchange and reduce information redundancy. Question TwoQuestion Two Report pages 11-14 12

13. JLARC's Analysis of DSHS Service Coordination Current Efforts Adopt Mixed Approach  Client Registry currently allows access to “legacy” information  Information changes include:  Implementing enterprise planning  Requested funds for Client ($8M) and Provider ($9M) hubs ( 2005-2007 biennial budget)  “Pragmatic” approach: major system replacement includes provider “hub” Question TwoQuestion Two Report pages 11-14 13

14. JLARC's Analysis of DSHS Service Coordination DSHS Formal Client Survey in Place  Formal survey of client opinions begun in 2001, conducted four times.  19 questions in total, two questions specific to service coordination. Question ThreeQuestion Three  Clients asked if they—strongly agree, agree, are neutral, disagree, strongly disagree to statements:  Someone from DSHS helps us with services from all programs  DSHS makes sure our services work well together Report pages 15-17 14

15. JLARC's Analysis of DSHS Service Coordination Majority of Clients Agree With Both Questions Question ThreeQuestion Three First Service Coordination Question of Clients Respondents Involved With Three or More Programs Who Agree That DSHS Helps with Services From All Programs Report pages 15-17 15 2005 SurveyTrend Combined “Strongly Agree” and “Agree”

16. JLARC's Analysis of DSHS Service Coordination Majority of Clients Agree With Both Questions Question ThreeQuestion Three Second Service Coordination Question of Clients Respondents Involved With Three or More Programs Who Agree That DSHS Makes Sure Services Work Well Together Report pages 15-17 16 2005 Survey Trend Combined “Strongly Agree” and “Agree”

17. JLARC's Analysis of DSHS Service Coordination JLARC’s Consultant Experts: Survey Can Be Improved Question ThreeQuestion Three  Overall design strong: But positive bias likely—seven changes suggested to make results more meaningful, such as:  Rephrase from “I am satisfied with service X” to “How satisfied are you with service X?” When determining client attitudes towards service coordination, surveys must be very carefully designed and administered to avoid bias. Improvements should be made to DSHS’s current methods. Report pages 15-17 Report’s Recommendation: DSHS should develop a plan to strengthen its client survey process so that it produces more meaningful results. The plan should address design features, survey procedures, and the analysis and presentation of data so that any potential positive bias is minimized. 17

18. JLARC's Analysis of DSHS Service Coordination Considerable Body of Service Coordination Literature Available Question FourQuestion Four  Experiences of other states and jurisdictions studied  Common themes include:  Attentive to what initiative is attempting to accomplish  Usually takes place at local level  Takes time and a lot of effort: not one event  Impacts for clients not well documented or assessed There are a number of consistent themes learned from the literature. One is to look at service coordination not as a single event fixed in time, but rather as an ongoing, continuous evolution. Report pages 19-20 18

19. JLARC's Analysis of DSHS Service Coordination Continuous Efforts Likely Most Important Report pages 21-22 19 1. Current efforts at coordination? A number of current initiatives 2. Improve computer systems? Attempts to improve information in place 4. Experiences of other states? There are lessons from other states/jurisdictions 3. Feedback from clients? Survey establishes process for feedback Initiatives take many different forms— involve just parts of DSHS or involve many participants outside of DSHS; and important to understand what is expected of an initiative. Recent changes in information technology—an emphasis on enterprise- wide information and “hub” strategies— can facilitate information exchange and reduce information redundancy. Client satisfaction surveys in place, but improvements needed to be more accurate. Recommendation included. Look at service coordination not as a single event fixed in time, but rather as an ongoing, continuous evolution.

20. JLARC's Analysis of DSHS Service Coordination Concurrence With Report’s Recommendation  Both DSHS and OFM concur with the report’s recommendation. JLARC Staff to contact for questions: John Woolley Phone: 360-786-5184 E-Mail: woolley.john@leg.wa.gov