Policy & Practice October 2018

The Magazine of the American Public Human Services Association October 2018

TODAY’S EXPERTISE FORTOMORROW’S SOLUTIONS

contents www.aphsa.org

Vol. 76, No. 5 October 2018

features

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12

Igniting the Potential The Making of a Health and Human Services Workforce Advocate

Disarming Data and Analytics An Old-School Tradition

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20

Putting People to Work Using Supports and Services to Change the “If” to “How”

Family Self-Sufficiency A Holistic View of Self-Regulation and Its Implications for Human Services Programs

departments

3 President’s Memo

24 Legal Notes

28 Association News 2018 ISM Conference Award Recipients

Building Well-Being by Creating a Culture of Inquiry

Social Advocacy and Law: Twitter or Shakespeare?

5 Locally Speaking

25 Improving Child Care Licensing Background Checks: The Legal Perspective

36 Do’ers Profile

Mecklenburg Community Resource Center Opens

Leslie Henderson, Quality Assurance Manager at the Utah Department of Workforce Services

6 FromThe Field

26 Technology Speaks

Building a Culture of Analytics: Health and Human Services Symposium for Action

Technology Tool Supports Better Outcomes for Children and Families

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October 2018 Policy&Practice

APHSA Executive Governing Board

Elected Director Brenda Donald, Director, DC Child and Family Services Agency,

Chair David Stillman, Assistant Secretary, Economic Services Administration, Washington Department of Social and Health Services, Olympia, WA Vice Chair and Local Council Chair Kelly Harder, Director, Dakota County Community Services, West Saint Reiko Osaki, President and Founder, Ikaso Consulting, Burlingame, CA Leadership Council Chair Roderick Bremby, Commissioner, Connecticut Department of Social Paul, MN Treasurer

Washington, DC Elected Director

Susan Dreyfus, President and CEO, Alliance for Strong Families and Communities, Milwaukee, WI Elected Director David Hansell, Commissioner, NewYork City Administration for Children’s Services,

NewYork City, NY Elected Director

Anne Mosle, Vice President, The Aspen Institute and Executive Director, Ascend at the Aspen Institute, Washington, DC

Services, Hartford, CT Affinity Group Chair

Paul Fleissner, Director, Olmsted County Community Services, Rochester, MN

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Policy&Practice October 2018

president‘s memo By Tracy Wareing Evans

Building Well-Being by Creating a Culture of Inquiry

I n this annual issue dedicated to impacting population health outcomes by better connecting human services with health and related sectors, we take a deeper look into how orientations such as social determi- nants coupled with tools like predictive analytics and data hubs are changing the face of health and human services (H/HS). Leveraging the power of the insights we gain when we examine the context in which people live, and the associated patterns and trends for whole populations, is no longer just wishful thinking. As you’ll discover in the pages that follow, the future is here. The combination of advanced ana- lytics, integrated systems, data hubs, and other innovations are enabling new insights and bridging the once seemingly impossible divide across the health and human services sectors. Moreover, links to education, justice, and housing systems, among others, are reshaping entire ecosystems within communities. At the heart of any of these efforts is our collective desire to optimize data to create meaning from it for the betterment of the health and wellness of families and communities. There is no doubt that talk of data analytics and integrated systems generates all sorts of reactions from H/HS leaders—from excitement to frustration to fear, sometimes all at the same time. You will want to read the confessions of our own Phil Basso (see feature article on page 12) regarding the trepidation those words trigger for him. And yet, as the non–tech savvy guy, Phil quickly gets at what we know is our toughest challenge in making connections across sectors—it’s not the physical linking of the systems—it’s

value to the desired future state? What excites the workforce? We know that most agencies still spend most of their energy using data to meet compliance with regulatory requirements, rather than leveraging it to drive longer term solutions. Within the practice and historical culture of agencies, there is little time for fully examining root causes or the neces- sary iterative set of strategic questions required to test and learn. Moreover, we have tended to focus on what we need in the way of modern technology and platforms without fully appreci- ating the role of the workforce and the families themselves in designing those modern interfaces. Finally, even when an agency has the benefit of the latest technology, such as machine learning through predictive analytics, we tend to underestimate how intimidating

fostering a culture and climate neces- sary to make these insights actionable. Building well-being through data optimization is about more than con- necting data systems, employing data standards, entering into sharing agree- ments, and generating automated reports through various analytics tools. It is intrinsically about the people and places that populate the data. It is about giving the workforce the capacity to see beyond numbers and to ask questions about the context and circumstances of families and communities. It is about generating ideas that we test and then learn from, repeating the cycle to get at root causes and co-create solutions. In sum, it is about creating a culture of inquiry—one that fully recognizes the power in stopping long enough to ask questions. Why this pattern? Why this result in this community? Who are we asking the questions about? What is the outcome we want? What drives

See President’s Memo on page 29

Image via Shutterstock

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October 2018 Policy&Practice

Vol. 76, No. 5

www.aphsa.org

Policy & Practice™ (ISSN 1942-6828) is published six times a year by the American Public Human Services Association, 1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2018. All rights reserved.This magazine may not be reproduced in whole or in part without written permission from the publisher.The viewpoints expressed in contributors’ materials are the authors’ own and do not necessarily reflect the policies or views of APHSA. Postmaster: Send address changes to Policy & Practice 1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036

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Policy&Practice October 2018

locally speaking By Rodney Adams

Mecklenburg Community Resource Center Opens

O n June 4, 2018, the Mecklenburg County Community Resource Center (CRC) opened to provide inte- grated health and human services (H/HS) to county residents. Within the first two months of operation, the CRC provided service to more than 18,500 people. This amounts to a 46 percent increase in number of customers served daily. Mecklenburg County, home to the city of Charlotte and surrounding towns, is in North Carolina and has a popula- tion of more than 1 million people. The CRC, located at the Valerie C. Woodard campus inWest Charlotte, is the first of six planned, place-based service sites strategically located throughout Charlotte-Mecklenburg. The vision is simple, to “Strengthen Individuals and Families, Promote Health andWellness, and to Build Communities.” The CRC seeks to fulfill these objec- tives by providing access to the following programs: the Supplemental Nutrition Assistance Program (SNAP); Medicaid; Temporary Assistance for Needy Families (TANF); emergency assistance; child support enforcement; veterans services; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); immunizations; child care assistance, care coordina- tion for children; and pregnancy care management programs and services. In addition, the CRC works with commu- Workforce Development Board, which provides opportunities that prepare people for education and available careers as well as connect businesses to skilled workers; n Loaves and Fishes , a local nonprofit emergency food pantry program that provides nutritionally balanced Photo courtesy of Mecklenburg County Community Resource Center nity partners on-site such as: n Charlotte Works , the local

The lobby of Mecklenburg County’s Community Resource Center.

numbers support the benefit to resi- dents of the CRC as a community-based, shared-service delivery model. Stabilizing families is a key com- ponent within the CRC. A strategic approach to utilize subsidized services through the lens of the social determi- nants of health (SDOH) ensures that families receive household stability while journeying on the pathway out of poverty. Building partnerships aligned with the SDOH will continue as an approach to ensure that residents can receive services necessary to stabilize their entire family in their community, in one visit and at one location, thereby removing transportation barriers. In the future, additional partners will provide services both on-site and adjacent to the CRC. Services will include assistance in housing stability, education, primary medical care, and behavioral health services. The CRC also serves as a partner to other major initiatives currently underway in the

groceries to individuals and families in a short-term crisis; and n Promising Pages , a nonprofit organization inspiring underserved children to achieve their dreams through book ownership. Each child visiting the “Kid’s Corner” departs with an age-appropriate book of their own to inspire life-long reading, assist in creating an inte- grated approach to stabilize families, and promote pathways to well-being. Of the 18,500 people who have come to the CRC since June, more than 11,524 customers accessed core services and the remaining 7,000 received assis- tance through other supportive services located within the center. During this time, 65 percent of the individuals served by Charlotte Works obtained full-time employment; more than 465 children received age-appropriate books through Promising Pages; and more than 1,500 families received emergency food to sustain their house- holds through Loaves and Fishes. These

See Mecklenburg on page 30

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October 2018 Policy&Practice

from the field By Rick Friedman and Anita B. Light

Building a Culture of Analytics: Health and Human Services Symposium for Action

S ince 2013, APHSA has surveyed its membership on topics related to the integration of health and human services (H/HS). Of particular note was the use of analytics and its ability to drive decision-making on service provision. Survey participants noted in 2013, in 2015, and again in 2018, that there has been some increased use of analytics over the last five years. Yet, for the most part, their information systems and the orientation of their staff were primarily focused upon addressing issues related to program integrity and tracking program efficiencies. Using these systems to identify the root causes of the client problems or contributing to the solution of structural barriers within the organization or community are largely untapped analytical capabili- ties at this point, at least in the field of human services. As a result of these findings and in discussions with Optum, an APHSA Strategic Industry Partner, we proposed convening a small number of senior-level H/HS thought leaders to talk about their experiences applying analytics to a diverse set of issues in child welfare, Medicaid, the Supplemental Nutrition Assistance Program, behavioral health, and a host of other H/HS disciplines. Thus began the nearly year-long planning effort that went into developing the Health and Human Services Symposium for Action (the Symposium) that was held at the University of Chicago’s Booth Business School’s downtown Chicago Gleacher Center, on July 20–22. More than 60 state and local H/HS officials from 18 states and 3 localities were in attendance, together with APHSA

Purpose of the Symposium The Symposium was designed to explore current practices and operations taking place in the H/HS

staff, consultants from Optum and The Lewin Group, and faculty from Chapin Hall—the University of Chicago’s pre- eminent research center dedicated to promoting the well-being of children, youth, and families.

See Symposium on page 32

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Policy&Practice October 2018

The Health and Human Services Workforce

The Making of a Health and Human Services Workforce Advocate PART 5

arly in my career as a clinical psychologist, I recognized the importance of patience. For anyone who has ever been in counseling, a secret about this process is repetition. Clinicians don’t mind repeating themselves. Most of us have been trained to understand that an individual’s growth is predicated on their openness to change, cognitive readiness, and emotional access. There tends to be a “right time” to integrate a new concept or to make a behavioral change. Therefore, therapists expect to have repetitive discussions about the same issues. In other words, quite often we view a client’s resistance or their “no” to mean “not yet.” Our studies of human nature provide us with the understanding that everything has its own timing. This is true for organizations as well.

By Beth Cohen

compelled to assess and address the needs of their workforce in an effort to positively affect health and well-being. Once again, “no” meant “not yet.” Today, as you know, the term “stress” is an important word in our organizational vocabulary. Fire agencies in many states are at the forefront of providing cutting-edge psychological and organizational interventions for their personnel. Decades have now passed since my research. No matter where I have worked—in human resources, occupa- tional health, employees’ assistance, risk management, or as the admin- istrator of my own businesses—the wisdom that change arrives in time has been reinforced. It appears that there must be a critical mass of like- minded individuals coming together and seeing the need. Just as we can’t change people until they are ready, the same goes for organizations. Five years ago, my work as a senior consultant and educator for the University of California Davis’ Center for Human Services allowed me to travel to many health and human services (H/HS) organizations throughout California. I discovered the incredible specialness of the H/HS workforce. Witnessing H/HS com- mitment to community welfare was stunning. I was quickly doused with the complexities and difficult chal- lenges that many H/HS professionals faced daily. I was impressed that despite long work hours, diminished resources, changes in laws and regu- lations, and reduced staffing, H/HS professionals continued to impact and save lives daily. I was awestruck! My concerns about H/HS workforce health and well-being grew as my work expanded across the nation. My train- ings, facilitations, and programs have always been designed to create safe environments to facilitate authentic sharing. I wanted to more fully under- stand the “real” experience of working inside agencies. I realized that despite geographic location or customer demo- graphic, H/HS staff shared similar stories and health concerns about themselves and their colleagues. Many individuals at different levels of the organizational hierarchy reported symptoms from significant

My work as an organizational psy- chologist has afforded me the great privilege of entering hundreds of organizations and meeting thousands of employees. Working in private industry, higher education, and public service, I have navigated organiza- tional terrain that has both amazed and saddened me. Early on I witnessed and heard stories of pain and feelings of helplessness. It was disheartening because I was meeting people who were doing such meaningful work and, yet, higher stress levels seemed to diminish their sense of meaning. I was eager to use organizational tools I had learned to try to make my own mean- ingful impact. I quickly realized that some organizations were not ready for change. Today, we would call this a fixed mindset. Patience. As I stated above, I often interpret a “no” as an obstacle rather than a door closer. Although my professional career has had several iterations, I have been clear about my purpose and vision—to build individual and organizational health and well-being. Despite where I have worn my profes- sional hats, my mission and passion have not wavered. My first big “no” came during my doctoral studies. I wanted to research firefighter stress, trauma, and resil- ience for my dissertation. My first challenge was to convince my doctoral committee that assessing the needs of those who were in service to their community was actually worthy and important information. I was thrilled when two large California fire com- panies opened their doors to me. Organizational resistance replaced my welcome after a few months when risk managers discovered that firefighters were openly sharing their experiences and emotional pain. Out of fairness to fire agency leadership, those were the days when first responder agencies feared, rather than embraced, the word “stress.” There was an assumption that using words such as “stress” and “burnout” could lead to disability and worker’s compensation claims. Despite this huge setback, I was not deterred. In fact, I was determined to continue. For several months, I went door to door to local firehouses. I eventually met fire chiefs who felt

Igniting the Potential is a recurring theme for 2018. In each article, we introduce our readers to various efforts underway in the H/HS workforce. If your organization has a compelling story to share about how you are supporting and advancing the H/HS workforce, we would love to hear from you. Contact Jessica Garon at jgaron@aphsa.org. Igniting the Potential

Beth A. Cohen is the Administrator of Organizational Mind Group, LLC.

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with agencies who are further along the road in addressing workforce challenges will inform us and allow us to better understand potential successes as well as challenges. 6. Through the development of orga- nizational needs assessments and consultations, we hope to provide county and state agencies with a personalized toolbox of offerings that can meet the cultural needs of each organization. 7. The H/HS toolbox will also include specifically tailored trainings, executive coaching, and assistance with installing health and well- being programming. Interventions will be designed based in the data collected. These evidence-based programs will be designed using the latest research in social neuro- science and best practices. 8. If study data reveal the need to rebrand H/HS cultures, we intend to address this process. Community education would then follow to provide a realistic understanding of H/HS work and its impact on both workforce and community members. 9. The definition of “first responders” may need to be expanded to include more H/HS professionals. Our H/HS workforce interacts and intervenes daily, often as the first line of contact. Also, the work expectations of H/HS profes- sionals during community crises, disasters, and critical incidents fall squarely within first responder responsibilities. 10. And even more data! We need baseline metrics, ongoing assess- ments, and post-intervention data. The goal is to measure outcomes and assess program effectiveness in order to inform and guide orga- nizational cultures in the most adaptive ways. We have come a long way from those days when the word “stress” threatened organizations. Igniting the Potential is a timely initiative as community needs and demands increase across the nation. I am excited to have come full circle. There is power in patience. Once again, “no” really did mean “not yet!” The time has arrived.

funding. Research consistently shows a significant return on investment when organizations focus on employee well-being. There are direct correla- tions between healthier workforces and employee satisfaction, motivation, meaning, and creativity. Organizations also report reductions in worker’s compensation and disability claims, as well as in absenteeism. In other words, healthy workforces serve their commu- nities more efficiently and effectively. Not surprisingly, the invitation to partner with APHSA was not only a great honor but also a fantastic culmi- nation of a long career committed to building workforces that thrive, not merely survive. A lot of us spend many hours at work for many years. Don’t we all deserve to feel productive, engaged, excited, and purposeful? In his article about data and analytics (see page 12), Phil Basso eloquently discusses their actual value—not as dictates, but as adaptive guides for us all to use. After a search of the relevant literature, our team discovered that there is minimal data collected, to date, on the health status of the H/HS work- force. Research on social determinants, those aspects of work-life that impact H/HS physical and psychological health, is also limited. We are gaining more and more clarity in this beginning stage of the Igniting the Potential initiative. Let me share a bit of what we know so far, our proposed research questions, and what we hope to offer: 1. We need data! What is the current state of H/HS workforce health and well-being? What are the primary health concerns? We aren’t sure yet. 2. We need more data! What aspects of H/HS work specifically impact (both positively and negatively) workforce health and well-being? 3. Once we have data, we need ana- lytics. The critical examination and analyses of all the data will inform and guide how we build an H/HS toolbox for individual and organiza- tional health and well-being. 4. We need H/HS experts! Building a national advisory committee of selected H/HS professionals will be invaluable to our efforts. 5. We don’t need to reinvent the wheel. Utilizing bridge building

stress, burnout, and secondary trauma. What was also striking were the high levels of empathy in the individuals I met. They truly desired to help, but often experienced helplessness. Many discussed their diagnoses, physical and psychological health challenges, as well as how the work affected their personal lives. Staff members reported significant frustra- tion when struggling with individual and organizational limitations as they attempted to meet client and customer needs. Management and staff consis- tently reported retention as a primary challenge and discussed issues they experienced while trying to solve the problem of keeping employees on staff. After a couple of years of bearing witness and collecting data, I felt com- pelled to share my concerns about the H/HS workforce. As a social scientist, I greatly understand the limitations of anecdotal evidence. However, the similar stories, frustrations, and symptoms I was consistently hearing about were clearly beyond coincidence. Many agreed with my assessment and evaluations. Despite the overwhelming entrenched H/HS cultural norms, I nonetheless met leaders who were already struggling and committed to updating their cultures. They were experiencing an urgency to focus on workforce health and well-being. I could feel it was the beginning of a movement. It would just take time. And then it was time! Health and human services leaders all over the nation began to identify their concerns for workforce health and well-being as well as the need for intervention. I have had the opportunity to work in those county and state agencies that were already traveling down this dual focused road—both looking outward to those served and also looking inward to those who choose to be in service. They were already reaping benefits. They reported increases in retention, staff morale, as well as employee engagement and productivity. It is now clear that addressing staff needs as they work tirelessly to better their communities will increase their impact. Additionally, attending to workforce needs will allow us to be even better stewards of government

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October 2018   Policy&Practice

Disarmin g Data & Analytics An Old-School Tradition By Phil Basso

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Policy&Practice October 2018

Some of APHSA’s dearest partners are squarely in this line of work, so I’m wincing as I reveal this. I grew up in the 60s and 70s, so for me a big technology breakthrough was when cassettes replaced 8-track tapes. I refuse to move on from CDs. My office neighbor Mo still laughs at me for installing the first apps on my phone, um, recently. And if someone uses words like “modular code” or “full stack development” in my presence, I immediately think of places to hide. Like I said, I have issues. That’s why it didn’t surprise me when at a recent data and analytics symposium we co-sponsored, initial discussions around the word cloud (ugh) brought forth terms like “complicated, frustrating, and daunting.” What did surprise me was my own word choice, which was “disarming.” As bad as technology feels inside, how do I feel when it comes to turning data into useful information and analytics to solve problems, make decisions, overcome preconceived notions, and generate evidence for what works? Well, I’m all in, and with pleasure. OK, I admit it. I have i s sue s with technology.

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October 2018 Policy&Practice

The main thing is for us all to stay focused on the desired state: to generate evidence for what works, join forces across system boundaries to solve problems, reshape services and supports for greater impact, and move system energy upstream to prevention and capacity-building.

I’m writing this as a witness to what APHSA’s members and their partners are currently accomplishing. In the challenging social and political envi- ronment we currently experience, it’s heartening to see such a greater focus on social and economic mobility and equity, justice and fairness. To see public health, health care, housing, education, criminal justice, commu- nity-based organizations, and public human services joining forces more and more. To see local and statewide data and analysis aims shifting from knowing to doing at a faster rate. In other words, to see a data and ana- lytics culture growing within our systems. Yes, it’s far from perfect out there. We still try at times to plug and play evidence-based practices without understanding why they work, and then we darken those word clouds when they don’t work for us. Ours is a field that’s been talking about service integration since the 80s. Still and all, a witness with issues like mine can still see that “a change is gonna come,” thanks Aretha. Why is a change coming? What are some of the factors that enable data and analytics capabilities to take shape, even in a forbidding climate? What does a culture of data and ana- lytics look like? Adaptive Leaders with Vision. If you have issues with organizational jargon, remember that I can relate. But the technical term “adaptive leader- ship” is worth the risk, because it’s so counterintuitive. We’re conditioned as leaders to know the answers—to be in charge like that. But the very essence of a data and analytics culture is not

knowing the answers and being open to what the data tell you. At the same time, leaders have to bring the vision and energy for the sustained effort. We care about data and analytics because we can’t otherwise partner to solve tough problems within families and communities. Good Governance. Data gover- nance and data management efforts have been structured and run with success in many places. Systems that are behind in this regard can easily find examples or procure experts for elements of good governance like data- sharing agreements; memoranda of understanding between parties; effec- tive and meaningful client-consent protocols; tiers of organizational gov- ernance for oversight, planning, and implementation; and related facilita- tion and project management skills and methods. In short, let’s stop telling ourselves why we can’t overcome the technical aspects of our aims and build the working knowledge to fulfill them. A Guiding Framework, Factors, and Indicators. Our readers are familiar with the Human Services Value Curve and Social Determinants of Health frameworks, and these have proven to be powerful ways to create shared meaning and language across programs and entities working with the same people. Underlying root cause factors and related indicators need to be modeled for a theory of impact to be defined and measures to be studied. Root causes are both family centered and structural, so this modeling ensures you don’t leave out major elements for study such as those contributing to disparate outcomes by race and place.

Staff, Partner, and User Engagement. Consistent with

adaptive change principles, solutions are identified and tested with input from everyone, not just technicians or those at the top. For culture change to really take hold, the people whose expertise and buy-in you need to sustain it have to know the movement belongs as much to them as anyone. Facilitation is a critical aspect of making this a reality, since this level of empowerment does not come naturally to most people. Keeping Terms Simple. This item may be self-serving on some level, except I’ve recently heard senior con- sultants from big technology firms and data science programs at big universi- ties asserting this. There’s a natural tendency to associate effective use of data and analytics with the technical platform and statistical methods you need to enable it. But just like turning on a TV or iPhone, we don’t all need to understand how it works. I’ve learned this about the big human services programs—program experts are needed to foster their integrity, but the rest of us need to stay focused on their impact. Understanding Basic Differences. It is useful to define four general types and uses of analytics, corresponding to the four Value Curve stages. This way they each receive their due, and systems avoid the common occurrence of getting stuck at the second stage: n Stage One analytics are used to study and improve program-specific integrity. n Stage Two analytics are used to study and improve client service and experience.

Phil Basso is the Vice President of Strategic Mobilization at the American Public Human Services Association.

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presenting health conditions across large populations and determine standard diagnosis and treatment pro- tocols. Rapid-cycle testing and refining service plans are very useful when working with a family on complex barriers to stability and mobility. In a desired state, each of these general approaches works in harmony, as problems are studied before trauma is occurring or getting worse. Other witnesses and observers would call out additional dimensions of “what it looks like” to have the desired culture take shape and evolve. The main thing is for us all to stay focused on the desired state: to generate evidence for what works, join forces across system boundaries to solve problems, reshape services and supports for greater impact, and move system energy upstream to prevention and capacity-building. If we keep this focus, we can aspire to an evolving national culture, where we all become better at openness, learning, critical thinking, partnership, and listening to each other. I know, that sounds very old school. But remember, I have my issues.

and therefore confident to do so. Successful systems are combining outside technical expertise from uni- versities and consultants with in-house teams of “translators” set up to ensure that, over time, those expert skills can be appropriately developed and trans- ferred in-house. It’s important to know that this capacity-building process may take a few years. Performance Management is a Learning Experience. Data and analysis are often associated with accountability for results, as they should be. But there’s a big difference between tracking performance along with related incentives and using a continuous improvement and learning cycle, within which analytics are used to study open questions about the “why.” APHSA uses the DAPIM™ method for embedding such cycles when solutions are not yet known, and other cycles can also be adopted. Using Big Data and Rapid Cycle Analytics. For example, health care and human services commonly use different approaches to analytics. Big data and analytics can be used to study

n Stage Three analytics are used to generate root cause–driven solutions at the family level. n Stage Four analytics are used to for- mulate root cause–driven strategies at the environmental and structural levels—“bigger than the family.” Messaging for Impact. As with keeping terms simple, there’s a natural tendency to describe what data and analytics are telling us by, well, talking about the data in a statistical fashion. But we know from brain science that a culture of analytics will more likely thrive on a foundation of asserting clear values, employing a metaphor for what we’re trying to create, sharing examples of what it looks like, and only then expressing a data-oriented narrative that fits with the first three messaging elements. Building Workforce Capacity Smartly. The most formidable barrier to a data and analytics culture might be the skill gap in your current orga- nization. The good news is that your workforce may relish the idea of this movement but isn’t feeling competent

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October 2018   Policy&Practice

Putting People to Work

Using Supports and Services to Change the “If” to “How”

By Jade Gingerich and Kelly Nye-Lengerman

Disability is both a cause and consequence of poverty. Disability is a cause of poverty as it leads to reduced earnings and opportunities by limiting access to education, housing, and health care. Disability is also a consequence of poverty because pathways to saving and earning are restricted or limited, along with systematic barriers that prevent full engagement in civic and community life.

then become eligible for some supports and services to enable them to return to work. This process is not only con- fusing and complex but, in many ways, the formal services system reinforces the belief that disability equals an inability to work. In the United States, the federal poverty level is defined as the per- centage of people with earnings in the last 12 months below $12,140 for a single person, and below $25,100 for a family of four. The poverty threshold depends upon the size of the family, the age of the householder, and the number of related children younger than 18. Currently, the U.S. poverty rate in the for people without dis- abilities is 11 percent; for people with disabilities that rate rises to 27 percent and up to 32 percent for individuals with cognitive disabilities, which include intellectual and developmental disabilities. The maximum check an individual on SSI can receive in 2018 is $750 per month. When supports are focused on reducing poverty, they do not account for disability. When supports are focused on disability, they

People with disabilities are more likely to be unemployed, underem- ployed, and living in poverty. For example, adult workers with dis- abilities may have to choose between working and gaining access to critical health care or choose between making a co-pay for a medication and paying rent. People with disabilities and living in poverty are placed in the precarious situations of having to make difficult decisions everyday with very few avail- able pathways. The labor force participation rate is the percentage of the population that is working or actively looking for work (as of June 2018, it was 33 percent for working-age people with disabilities compared to 78 percent of people without disabilities). 1 The lack of workforce participation for some people with disabilities may be due in part to being helped to apply for or receiving supplemental security income (SSI). This eligibility process requires individuals to document their inability to work to receive the benefit. However, once they are found eligible for SSI, and receive the benefit, they

often do not consider employment and poverty. We need to recognize the complex interplay between disability and poverty in our social services system and invest in changes. Employment and education can be pathways out of poverty. But before we can improve those pathways, we have to challenge the myths that perpetuate poverty and disability in the first place. Regardless of training, professional certifications, we need to acknowledge that all people carry stereotypes and beliefs about people, including people with disabilities and those living in poverty. As support professionals we need to challenge our beliefs and adapt our practice to ensure that we are sup- porting pathways out of poverty. Myth: You can tell who has a dis- ability and who does not. Fact: Disability crosses ethnicity, gender, age, geography, and socio- economic status. Disabilities are not always obvious. Learning disabilities, attention deficit disorder, mental health, and chronic health are all types of disabilities. We cannot determine a

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SSI recipients are substantially more likely to be inactive in employment, school, or service programs; have sub- stantially higher rates of arrests; and have higher dropout rates. 6 The Promoting Readiness of Minors in Supplemental Security Income (PROMISE) project, created under the Consolidated Appropriations Act, 2012 (P.L. 112-74), provided funds for activities to improve the outcomes of child SSI recipients and their families. Six model PROMISE demonstra- tion projects, including Arkansas, California, Maryland, New York, and Wisconsin, and ASPIRE (Achieving Success by Promoting Readiness for Education and Employment) demon- stration projects in Arizona, Colorado, Montana, North Dakota, South Dakota, and Utah, received five years of funding through the U.S. Departments of Labor, Health and Human Services, Education, and the Social Security Administration. PROMISE was intended to build an evidence base on the effectiveness of promising interventions related to the transition from school to postsecondary education and employment. Parents and youth can request and have any person they want attend and partici- pate in their individualized education program (IEP) meetings. PROMISE sites recruited 13,444 youth between the ages of 14 and 21, half of whom were randomly assigned to receive a series of enhanced inter- ventions to improve their educational and employment outcomes. Some of the interventions included: Case Management. A whole family approach was used, along with persis- tent, consistent ongoing outreach and engagement. Smaller caseloads and longer time frames to allow for inter- mittent engagement were critical to the success. Intensive support to estab- lish linkages to existing resources and follow up/follow through was also key. Career and Work-Based Learning. Paid work while in high school is one of the greatest predictors of paid work post high school. 7 Customized employ- ment, where a trained job developer identified an individual’s strengths and aligned those skills with specific tasks based on employers’ needs, was one means of ensuring all youth, no matter the degree or nature of their disability,

person’s capabilities or worth just by looking at them. There are many more invisible disabilities than visible ones. Today, in the United States, children and older adults are populations more likely to be affected by poverty. Individuals with disabilities living in poverty do not always look as we would expect. Myth: People who have a disability, who are low-income, or who receive benefits do not work or cannot work. Fact: The majority of people living in poverty in the United States, including those who receive public benefits, are working. 2 The Bureau of Labor Statistics (BLS) also indicates that, despite working 27 weeks or more per year, 9.5 million people were the “working poor.” 3 Most people with disabilities can and want to work, even if they need some support to do so. And living in poverty is not just about being poor financially. Poverty is multidimensional and can affect all aspects of life for an individual and their family. Poverty results in poor health outcomes (e.g., life expectancy, child mortality, disease rate), social and economic isolation (e.g., unem- ployment, underemployment), and decreased social and emotional devel- opment (e.g., safe housing, educational access, malnutrition, hunger).

Myth: There are many resources for people with disabilities. Fact: Most people with disabilities in the United States do not receive any formal supports or services. For example, there are an estimated 4.71 million people in the United States with an intellectual and or developmental disability, with only 31 percent or 1.46 million, known to be receiving services from their state department of health and human services. 4 Not all individuals with disabilities are eligible for dis- ability-specific services, which means the capacity of the broader poverty support system needs to evolve to be able to support individuals, particularly those with non-obvious disabilities, effectively, rather than assuming that some other agency can or will. There are many examples of individuals, even those with significant disabili- ties, working at and above minimum wage. In many cases, it starts with the expectations of support professionals (i.e., teachers, social workers, case managers, rehabilitation counselors). Changing Expectations To change the system, we have to change expectations of staff, families, and individuals. Raised expectations are a key to supporting people into pathways to employment and educa- tion. The change starts with individual professionals at all levels of the system. When helping individuals with dis- abilities gain access to SSI, it should be with the understanding that they are demonstrating their inability to work to access SSI, so they may then be able to get the supports and services they need to be able to work. We need to recognize that all people with disabilities, even those living in poverty, have the poten- tial to go to work and pursue additional education to improve their life’s trajec- tory. Employment and education are pathways out of poverty and children on SSI, in particular, need to be supported on that path. The age 18 SSI redeter- mination, using adult criteria, does not take into account family income, but is based solely on ability or inability to work. As many as one third may lose their eligibility during the redetermina- tion process. 5 Yet, compared with other young adults, after age 18, former child

Jade Gingerich is Director of Employment Policy for the Maryland

Department of Disabilities. She also serves as

Project Director for Maryland PROMISE.

Kelly Nye- Lengerman is a Research Associate at the University of Minnesota’s

Institute on Community Integration.

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Staff also needs to know who on their caseloads is on SSI, who is approaching age 18 redetermination, and emphasize the message that disability does not mean inability to work. Youth on SSI should be encouraged and supported to access pre-employment transition services (Pre-ets) from vocational rehabilitation. Note that not all youth on SSI have IEPs and they do not have to have an IEP to be eligible for Pre-ets. America’s Job Centers (formerly One Stop Career Centers) are another important resource for out-of-school youth (up to age 26; other services are available for individuals older than 26), whether or not they have a disability that can connect them to training and other resources to aid in employment. SSI may be an important short- term step to provide a steady stream of income to a family in need, but it should never be viewed as the only option, particularly for children under age 18. Disability should never be viewed as synonymous with not being able to work. Helping direct staff understand the resources and information available, making certain they actively engage youth and family members, and always talking about work from the framework of how rather than if a person can work, are important starting points for changing the narrative and beginning to break the cycle of poverty for individuals with disabilities. For more information on how youth on SSI and other individuals with dis- abilities can work and the resources available to help in your state, visit https://www.ssa.gov/redbook/eng/ resources-youth.htm or http://www. promisetacenter.org/home Reference Notes 1. Brennan-Curry, A. (2018). nTIDE June 2018 Jobs Report: Modest Downturn in Jobs Ends Extended Run for Americans with Disabilities. Retrieved from http://bit.ly/2xBt6gR 2. Nord, D., & Nye-Lengerman, K. (2015). Employment for people with disabilities in poverty: A need for national attention. Policy Research Brief, 25 (1), Minneapolis,

Incentives Planning and Assistance is available to anyone seeking informa- tion on how to work while minimizing or eliminating any impact on SSI. Changing Your Narrative and the Narrative and Work of Your Staff A new narrative on poverty, disability, and employment needs to be developed to address the myths and miscon- ceptions. While data are still being collected, PROMISE already shows evidence that an emphasis on employ- ment and higher expectations can change outcomes for youth on SSI. But systems that support youth on SSI and their families need to change as well. Many youth on SSI and their families do not participate in IEP meetings and thus miss out on impor- tant resources and connections. Staff should encourage families and youth to participate in IEP meetings and take advantage of transition planning and services that support employment.

were able to participate in paid work. Job coaches and other supports were also critical supports. Benefits Counseling/Financial Capability. The low unemployment rates of child and adult SSI recipients are often driven by a fear of benefit reduction or loss of Medicaid. 8 There are a number of work incentives avail- able to youth and families on SSI to increase their earnings without nega- tively impacting benefits, such as the Student Earned Income Exclusion, Plan to Achieve Self Sufficiency, Medicaid Buy In, and others. Community Work Incentive Coordinators are trained to assist youth and families in navigating these options. Given how little monthly income SSI provides, and how generous the work incentives are, most people on SSI are likely to be better off finan- cially by working. Many SSI recipients also need support in managing their finances effectively. Financial education and one-on-one coaching is provided; as their incomes increase, families are also able to save and follow a budget. While PROMISE youth received these services as an intervention, Work

MN: Research and Training Center on Community Living at the University of Minnesota.

See Work on page 36

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Policy&Practice October 2018 20

A Holistic View of Self-Regulation and Its Implications for Human Services Programs FAMILY SELF-SUFFICIENCY By Elizabeth Cavadel and Jacqueline Kauf

umans are wired to be goal oriented. Many of our daily behaviors are governed by simple goals that are so routine we are barely aware of them. For example, most of us would not

H

consider our daily drive to work to be motivated by goals. Yet, we get in the car in the morning because our goal is going to work and we choose when to drive because our goal is getting to work on time. We get to work on time because we have a goal of completing our work, of keeping our jobs, or of using our income to pay for household necessities. These more simplistic goals are likely to support larger goals related to holding that specific job, including mastering a particular skill, achieving a financial goal, or moving ahead in a career. This cascade of simple, short-term goals that drive more complex, long-term goals is the foundation for much of our lives.

October 2018 Policy&Practice 21

Long-term, complex goals, such as financial and familial stability and security, are often at the heart of human services programs. Supporting people in successfully achieving their goals, however, can be challenging. Although much progress has been made in recent decades, many gaps remain in moving families living in poverty toward self-sufficiency. As a result, there is growing interest in applying new understanding from psychology and brain science to help program participants not only identify goals related to employment and well- being, but also more effectively attain those goals. Goal setting and goal pursuit have long been studied as important ingre- dients for success across a variety of contexts 1 , and evidence suggests that specific psychological skills—known collectively as self-regulation skills— are needed to successfully set, pursue, and achieve personal goals. 2 Figure 1 presents a conceptual framework for how self-regulation supports goal achievement and personal goals related to employment and increased well-being and self-sufficiency.

trying to achieve goals far in the future, even in the face of challenges. 8 Self- efficacy is a person’s belief that he or she can succeed. Evidence suggests it powerfully influences outcomes across many contexts, including academic achievement, job retention, and parenting. 9 In practice, the skills of self- regulation do not fall so neatly into categories. Neuroscientists and psy- chologists have long recognized that cognitive and emotional skills interact and the expression of personality is influenced by, and influences, both cognition and emotion. 10 In daily life, people draw on cognition, emotion, and personality skills simultaneously. As Figure 1 shows, self-regulation skills enable people to set and pursue goals. For instance, people use execu- tive function and metacognition to plan and organize their approach to solving a problem during goal setting, and to initiate a task and prioritize, organize, and manage their time most efficiently to pursue a goal. 11 Emotional skills, motivation, and grit may help people persist toward goal achievement. Practice in setting and pursuing goals, especially when goals are broken into smaller steps or milestones, can support and enhance self-regulation skills. 12 The framework in Figure 1 suggests that a certain mind-set is a necessary precursor to setting and pursuing goals, based on evidence that people must be willing to change before they take steps toward change. Aspects of personality, such as self-efficacy and motivation—may influence one’s readiness for change. The framework also proposes that, after pursuing a goal, people assess the extent to which they succeeded, learn lessons from their experience, and, if they did not fully achieve their goal, revisit earlier steps in the process when they might have faltered and try them again. Such feedback and self-reflection (which draw on skills such as meta- cognition and cognitive flexibility) can prompt people to change both their mind-set and behaviors to meet their goals. 13 Thus, in the frame- work, the goal achievement process has four components—readiness for change, goal setting, goal pursuit, and

What is Self-

Regulation? Self-regulation is an umbrella term describing skills across three categories: cognitive skills, emo- tional skills, and personality factors. Cognitive skills are made up of executive function skills, as well as selective attention and metacognition. Executive function skills help people regulate and control their actions and are usually thought to include inhibitory control (the ability to stop automatic or inadvisable actions in favor of more appropriate behaviors), working memory (the ability to hold information in mind while performing complicated tasks—for example, fol- lowing multistep directions), and cognitive flexibility (the ability to hold more than one idea at a time, and to switch between tasks or thoughts as needed to adapt and adjust to new circumstances). 3 Selective attention is the ability to attend to the most impor- tant or relevant aspects of a task while filtering out distractions, 4 and meta- cognition is the ability to reflect on one’s own thoughts and actions. 5 Self-regulation skills also include understanding and regulating emotions. Understanding emotions enables people to use physiological, visual, and environmental cues to identify feelings in themselves and others. Regulating emotions involves using strategies to make emotions manageable or useful. Emotions can focus and guide attention and action and can be motivational. 6 Regulating emotions can include lowering one’s level of expression (cooling off when angry) or raising one’s level of expres- sion (also called up-regulating) so that one can react to demands and persist. Aspects of personality—in particular, motivation, grit, and self-efficacy— interact with emotional and cognitive skills. Motivation drives people to pursue, persevere, and accomplish tasks. Determining what motivates people can be challenging. Incentives— both external (such as money) and internal (such as satisfaction)—are motivating. 7 Goal setting in and of itself can also be motivating. Grit often is described as motivation over a long time, and it enables people to persist in

Elizabeth Cavadel is a Senior Researcher at Mathematica Policy Research.

Jacqueline Kauff is a Senior Researcher

at Mathematica Policy Research.

Policy&Practice October 2018 22