Best Practice Research Report

Washington County Human Services System Analysis
Best Practices in Human Services
June 2007
This review is prepared for the Washington County Human Service System Analysis
Implementation Team. The review addresses current practices in Washington County as
well as some practices in other counties of Pennsylvania that were identified by
Implementation Team members. Some relevant practices identified through research in
other parts of the United States are also included. This review is not intended to be a
comprehensive scan of best practice in the human services field. It is focused on specific
areas of interest that have been identified by the Washington County Steering Team and it
is organized around the three domains making up the primary “areas of influence” affecting
the Washington County human services system – access to services, service provision,
and agency interaction. There is no attempt here to describe each practice or program in
detail. Web-based sources of additional information are provided in footnotes. The reader
is encouraged to follow the links provided in the footnotes to learn more about a particular
practice or program referenced within this review.
The Current Context of “Best Practice” In Human Services:
There are many practices and programs that may be referred to as “best practice” in the
literature; however, there is little consensus about how the term is defined. Best practice is
defined by some as research-based practice; that is programs or approaches that have
been rigorously tested through controlled studies and proven to be effective in achieving
desired results. Other definitions of “best practice” are much less rigorous and some
amount to little more than an intuitive perception based on limited anecdotal evidence that
the practice or program is better than familiar alternative approaches. Thus, the term “best
practice” is highly subjective ranging from defined programs that have been proven to
work, to programs and approaches that seem useful to those persons engaged in the
Since few programs and practices have been studied sufficiently to prove they are
effective, most of the discussion included in this review is based on programmatic
approaches and types of interagency interaction that hold some degree of promise for
improving human services and the systems that support the delivery of these services.
Thus, we shall use the term “promising practice” for approaches that appear to have merit
or are thought to be worthy of consideration in the context of improving services and
programs for consumers and/or the systems that deliver these programs. We shall use the
term “best practice” in this review only when the practice (or in most cases a specific
program) has been proven effective through evaluative studies.
Access to Services:
This domain includes practices that promote and enhance the necessary processes that
connect consumers to needed services. Such processes include outreach, information and
referral, and the collecting and sharing of consumer information among community
agencies. Practices that make it as easy as possible for the consumer to gain assistance
and support are of interest within this domain. We wish to identify and adopt those
practices that encourage the best possible match between the consumer with needs and
some type of service or program designed to meet those needs.
Promising practices identified by the Washington County Implementation Team focus on
outreach and coordinated information and referral services.
Senior Outreach and Referral (SOAR) is a program piloted in Greene County that is
based on the Gatekeeper Case Finding & Response System developed by the late
Raymond Raschko in Spokane, Washington. The program recruits persons who may
come into contact with isolated elderly citizens (gatekeepers) and trains them to identify
signs of stress and limited functioning among elderly citizens they might see during their
normal daily routine. People working as postal carriers, utility workers, bank personnel, etc.
who may have contact with elderly community residents are suitable gatekeepers. The
Gatekeeper program is considered “best practice” since it has been evaluated and has
proven to be effective in identifying socially isolated elderly persons and enrolling them in a
clinical case management program. In Greene County, elderly community residents
identified by the trained gatekeepers are visited by a professional SOAR team with mental
and physical health expertise in order to assess their need for services, link them to any
needed services, and follow-up to assure that services are provided. Expected outcomes
of the SOAR program include:
 Increased community services to older persons,
 Reduced admissions to psychiatric in-patient facilities,
 Reduced premature nursing home placements, and
 Reduced suicide rates among the elderly.
Other promising practices identified by the team focused on Centralized Intake and
Referral Services in Northampton County and Westmoreland County. Both of these
systems provide the public with access to a 24 hour a day – 7 days per week telephone
service where information about services and supports available in the community is
available. Both systems also provide access to crisis/emergency services on a 24-7 basis.
Information and Referral (I&R) services are available to community residents of all ages
and across all major service systems including Senior Services, Children and Youth, Drug
and Alcohol, and Mental Health. Information about a wide range of social services may be
accessed through these I&R services from staff trained to be familiar with county service
systems and access points to different types of services. Initial screening is provided by
the I&R worker and referrals made as may be appropriate based on information provided
by the caller.
A searchable database of information about human service agencies and services they
provide is available in Greene County. Known as Find Out, this on-line service provides a
wealth of information about local agencies and services, and how to access services.1 The
Find Out system also provides a toll free telephone number for consumers to talk to an
information specialist during normal weekday hours.
2-1-1 systems are examples of promising practice in many states and localities across the
nation. 2-1-1 is a national abbreviated telephone dialing code for free access to health and
human services information. Current 2-1-1 systems cover all or parts of 41 states. 2-1-1 is
not currently available in Pennsylvania, although United Way of Pennsylvania is
advocating for the federal 2-1-1 ACT to provide funding for establishment of the 2-1-1
system nationwide.2 Promising practices in the area of centralized I&R services include
web-based data systems that supplement local or statewide toll free phone services. A
statewide on-line service has been established in West Virginia that is linked to a 2-1-1
phone service connecting consumers to local I&R services where they exist and also
providing information in a searchable database. 3
Other promising practices in the area of access to services that may be worthy of review
are the Standards for Professional Information and Referral published by the Alliance of
Information and Referral Systems (AIRS).4 These standards define appropriate practice in
providing a centralized I&R service. The state of Virginia has designed their 2-1-1
information system based on the AIRS standards.5
Smart Card technology is emerging as a promising practice in establishing and
accessing integrated consumer databases that have the potential to eliminate duplicative
data collection by multiple agencies. Such a system allows information about a particular
human services consumer (or family) to be stored on a data card and controlled by the
consumer. The consumer can then make the data available to provider agencies as may
be needed. This type of system is being piloted in the health care field but can also be
used to store basic intake and assessment data for persons who receive a wide range of
human services from multiple agencies, thereby eliminating the need for each agency to
repeat the intake and assessment process. The Western Governor’s Association has been
developing such a system known as the Health Passport Project in three pilot sites
(Bismarck, ND; Cheyenne, WY; and Reno, NV) and evaluation of that initiative identifies
several key steps toward implementation of such systems.6
Service Provision:
This domain includes direct services and programs including assessment and planning, a
wide range of programs and support services, and the provision of aftercare and follow up.
Case management or care management services are also addressed within this domain.
Programs and services identified by the Washington County Implementation Team as
promising practice focus on those programs that provide for a coordinated approach
across two or more agencies.
The Washington County Co-Occurring Disorders (COD) or MISA Pilot has provided a
best practice model that has been evaluated for how agencies work together to address
the treatment needs of clients who exhibit both mental illness (a psychiatric disorder) and a
substance abuse disorder (MISA). The pilot has resulted in a considerable degree of
integration among services and programs offered by several independent agencies to
better address MISA issues. This coordinated approach among multiple drug/alcohol
treatment programs and mental health agencies increases awareness of the needs of
MISA consumers and increases the options available for effective treatment. Joint training
of staff in MISA related issues is provided and case management services assist the MISA
consumer in navigating the treatment options available across the partner agencies.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has
identified four evidence-based best practices for treatment of certain types of consumers
experiencing co-occurring disorders.7
Dialectical Behavioral Therapy (DBT) is a behavioral, problem-solving approach
for treating patients with multiple disorders.8
Multisystemic Therapy (MST) is designed to address Juvenile Offenders and
focuses on the factors in each youth’s social network that contribute to anti-social
behavior.9 This approach is also recognized as a best practice by the Promising
Practices Network maintained by the RAND Corporation.10
Seeking Safety is a program for clients with a history of trauma and substance
abuse. It focuses on coping skills and psycho-education.11
Trauma Recovery and Empowerment (TREM) is specifically designed to assist in
trauma recovery among women with histories of exposure to sexual and physical
abuse. This intervention has been shown to be effective with women experiencing
problems related to substance use and exhibiting trauma symptoms.12
The Washington County Drug Court (or Treatment Court) has been identified by the
Implementation Team as a promising practice in Washington County. The court was
established in 2004 and has proven to be an effective practice in reducing recidivism and
providing treatment services to court involved persons with co-occurring disorders. The
drug court program works closely with the COD pilot in the county and provides a clinical
team to monitor the client’s progress and assure appropriate services are provided.
Nationally, many drug court programs have been established and adapted to local
community needs and there are several variations on the original theme across the
country. A 2006 report by the National Institute of Justice concludes that drug court
programs reduce recidivism but more research is necessary to determine the effectiveness
of the programs for specific types of clients and to identify the most effective processes. 13
In Washington County where the drug court program works closely with the existing multiagency effort to address co-occurring disorders, these two promising practices would tend
to strengthen one another.
The Washington County Student Assistance Program is another promising practice
identified by the Washington County Implementation Team. This program establishes a
core team within each school that is charged with addressing student behaviors that
interfere with school achievement including substance abuse issues. The SAP process
links the core team within a school to community agency resources through designated
liaisons to mental health and drug abuse programs. A “Student Assistance Coordination
Team” has been established to promote collaborative approaches among schools and
community agencies and provide a structure for joint planning and service delivery. The
coordination team assesses needs, provides training and technical assistance, and
compiles and distributes information. Best Practice Guidelines14 have been developed for
SAP programs in Pennsylvania and an online reporting system has been developed. 15
Best practices in the area of service provision (intervention and treatment) that have
particular applicability to school age children include:
Multidimensional Family Therapy (MDFT) is recognized by the Office of Public
Health and Science - U.S. Department of Health and Human Services as a
research-based best practice.16 This program is designed to treat drug abuse
among teens and manuals are available to teach the program to clinicians with
high fidelity to the model. Goals of this approach focus on reducing negative
factors while promoting productive processes in the life of teens.
Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is an
additional best practice that has been reviewed by the RAND Corporation for the
Promising Practices Network.17 This program is a group intervention for children in
grades six through nine. The program is aimed at relieving symptoms of posttraumatic stress disorder (PTSD), depression, and general anxiety among children
exposed to trauma.
Other promising practices identified by the Implementation Team in the area of Mental
Health and Mental Retardation services are related to:
 Incident Management Policies and Procedures to protect the health and
safety of MH/MR consumers.
 The Healthcare Quality Unit of Southwestern Pennsylvania which provides
healthcare training and technical assistance to residential programs for the
mentally retarded.
 Independent Monitoring for Quality (IM4Q) which provides independent
monitoring of quality within programs for the mentally retarded. Independent
monitoring teams interview consumers and share the results with providers and
funding agencies in order to improve the quality of services.
 The Family Guide to the Individual Support Plan in Pennsylvania is a user
friendly guide about how family members can be involved in developing the
individual support plan for a family member.
An additional area of interest identified by the Washington County Implementation Team is
some form of lead or integrated case management service that would assist consumers
in navigating services across different human service agencies.
One possible tool for moving toward a more integrated case management system is the
Family Development Credential in Pennsylvania (FDC-PA)18. This training program has
been identified as a promising practice in Washington County. FDC-PA is a training and
credentialing program designed to improve the practice of front line workers in order to be
more strengths-based in their approach to working with families. The training program is
based on the Empowerment Skills for Family Workers curriculum developed by Cornell
University. This approach focuses on the development of a partnership with families that is
designed to assist the family in setting their own goals. The Family Development
Credential is one way of assuring common training and orientation of case workers across
multiple community agencies.
Family Group Decision Making (FDGM)19 is a best practice that has its roots in case
work related to child welfare and child protection. This approach has been evaluated in a
number of diverse sites both within the United States and in other countries. 20 The
American Humane has developed a summary of the research related to FGDM which
concludes that the approach is effective in involving families in decision making about
children at risk of abuse and neglect and in promoting kinship care.21 In Washington
County, FGDM is used as a supportive, non-adversarial approach that encourages families
to develop a good family plan in partnership with community and government agencies
serving the family. Referrals for FGDM are not limited to child welfare in Washington
County and the practice can serve as a model for a family-centered and strengths-based
approach to developing cross-agency service plans for families with a variety of needs
including aging services, juvenile and adult probation, education, mental health, and
substance abuse services.
Integrated or coordinated case management is closely aligned with promising practices in
client data management and several information management approaches have been
developed. Smart Card technology was briefly discussed earlier under Access to Services.
Other systems have been developed by major information technology companies such as
Oracle and IBM. The Oracle product is known as Integrated Solution to Case
Management for Social Services22 and the IBM product is IBM Integrated Case
Management Solution for Social Services and Social Security with My SAP™ 23.
These technology based solutions are; however, only tools that can be used to support a
more integrated system of case management. Although some insight into the issues
involved in developing a more integrated case management system across multiple
agencies may be gained from looking at the data management issues, these data
management systems are examples of promising practice in managing data and are not
examples of best practice in providing a coordinated and comprehensive approach to case
management services that supports consumers across diverse services and programs.
Some best practice issues related to case management for the elderly who have multiple
needs has been summarized in a paper published by the National Association of Social
Workers.24 This paper concludes that experienced professionals (Master’s level social
workers) are best at providing case management services given the complexities of the
multiple functions a case manager must carry out. Another good summary of issues
involved in moving from “case management” to “service coordination” may be found in a
best practice brief prepared by Michigan State University in 1999.25
Agency Interaction:
This domain relates to how local agencies and organizations interact with one another and
the relationships among them. It addresses issues of effective communication, interagency
cooperation, coordinated service delivery, and building collaborative service systems.
Some of the issues related to agency interaction have been discussed previously under
the other two domains in cases where improved agency interactions have resulted in more
integrated consumer access and service provision. The quality and nature of agency
interactions affects the other two domains identified. Good agency interaction improves
both access to services and service provision.
Most best practices specific to this domain are related to building new structures and
improving relationships that promote planning across agency boundaries, the sharing of
administrative costs, and the development of common data management systems.
Another characteristic of this domain is related to scope of the integration effort across
multiple agencies. The scope of the effort generally focuses on a specific group of
consumers or on a subset of services and programs. Numerous examples of integration
efforts focused on young children (birth to five years) have recently been identified by the
national organization Zero To Three26 and the Pennsylvania BUILD Initiative is working
toward more integrated service systems for families with young children within the state. 27
Other efforts such as those driven by the Pennsylvania Child and Adolescent Service
System Program (CASSP) are focused on children and adolescents with mental health
service needs.28
Some promising practices within the agency interaction domain have been identified by the
Washington County Implementation Team. These include:
Washington County Student Assistance Program – This practice has been
previously discussed as a promising practice in service provision. It is also an
example of how several local agencies work together within accepted guidelines
and protocols to serve a specific group of consumers.
Greene County Senior Outreach and Referral (SOAR) and the Washington
County Co-Occurring Disorders Pilot (COD) are also examples previously
discussed under other domains that have implications for how interagency
interactions can be enhanced to better serve consumers.
Several counties in Pennsylvania and across the country have used the principles inherent
in the CASSP initiative to build cross-agency systems of care for children and adolescents
with serious emotional disturbance.29 Families with children and youth experiencing
serious emotional disturbance require a high degree of interagency coordination due to the
serious nature of the problems.
The Center for Effective Collaboration and Practice makes available monographs for
those wishing to work toward more integrated systems of care.30 The Center’s website
dedicated to promising practices in children’s mental health31 provides much information
related to system building. One volume from the 1998 promising practices series
summarizes strategies identified through a study of nine sites that were determined to be
the most promising tools for building systems of care.32
Greene County MAGIC (Making a Great Impact Collectively) is another interagency
initiative identified by the Washington County Implementation Team as a best practice in
agency interaction. Greene County MAGIC is an example of a coordinating structure that
has been built to improve service delivery across many partner agencies and organizations
in order to improve the general well-being of county residents.33 This standing structure
can be called upon to provide for collaborative planning and development around a range
of issues. Currently, Greene County MAGIC has six standing teams and two ad hoc teams
working on different issues related to the human services system and improved community
well being.
Changes in practice toward more integrated service systems require that new structures
are built to sustain the change. Some advantages of community structures such as Greene
County MAGIC are enhanced communication, opportunities to build collective vision
across diverse programs and service systems, and the ability to use the existing
collaborative to plan and implement new community initiatives without having to build a
support structure each time a new effort is launched.
A brief scan of the existing literature related to best practice in agency interaction has
identified several “best practice briefs” or “guides” that summarize lessons learned and
provide useful guidance for local communities working toward more efficient and integrated
systems of care that better meet consumer needs.
One such guide was prepared for CIO Magazine which is a periodical for Chief Information
Officers of large corporations. This article titled: A Travel Guide to Collaboration34,
discusses collaborative efforts by several large U.S companies in order to “jointly create
what they cannot produce efficiently on their own”. Although the guide discusses
collaboration in the business world, the lessons and issues are no less applicable to
collaborative efforts among human services agencies and organizations.
Another guide was developed by Michigan State University as part of the Best Practice
Briefs series. This brief titled: Developing Community Systems of Care,35 provides
excellent guidance to local collaborations of agencies and organizations interested in
developing more integrated service delivery systems.
The Pennsylvania Department of Public Welfare began the Integrated Children’s
Services Plan (ICSP) initiative in 2004. The primary goals of this initiative are focused on
establishing a more integrated service system for children and youth and their families. A
total of 27 counties have designated themselves as Tier One counties for the 2007-2008
fiscal year and have submitted plans for continued efforts toward an integrated service
system to serve the birth to twenty-one age group. The ICSP initiative cuts across all three
domains identified by Washington County; however, it is primarily a system integration
approach that requires changes in agency practices and is, therefore, discussed under the
agency interaction domain.
Northumberland County’s ICSP has built upon the System of Care initiative supported
in Northumberland County with federal grant funds. The System of Care primer 36
developed by the National Technical Assistance Center for Children’s Mental Health at
Georgetown University is a source of promising practices information related to building
more integrated child mental health systems. Northumberland County continues to work on
service integration issues and has developed a plan for systemic changes. To date, the
county has seen increases in family involvement and parent representatives serving on
agency advisory boards. A second priority in Northumberland County has been to build
partnerships with schools focused on reducing the number of school drop-outs. Future
plans are being carried out by seven committees including committees working on an
integrated intake system, integrated case management, and an integrated data
management system.
Tioga County, PA is one of the few examples of demonstrated practices in service
integration in the nation. This county has an extensive history in building an integrated
system across major human services delivery systems dating to 1985 when Mental Health,
Children and Youth, Drug and Alcohol, and Mental Retardation services were merged
under a single umbrella agency37. The Tioga County system provides family based-case
management services and the umbrella agency developed its own integrated data
management system. Promising practice models in Tioga County may be worthy of
consideration; however, many of the innovations would likely not have been possible
without the merging of agencies under a common administrative structure. Although
considerable progress has been made related to agency interaction and the integration of
services in Tioga County, the unique structure is often not compatible with the continuing
focus on categorical requirements by state and federal agencies in areas of billing,
accountability, and data management. The Tioga County ICSP plan indicates that these
external requirements continue to present barriers to service integration even when
separate agencies are merged at the local level.