Collectively addressing the environmental and social factors that influence health, a process known as health and human services integration, is not a new concept in the United States, but our understanding of the value of integration is far ahead of our implementation of integration. Visionary leaders have shown that real integration is possible, that integration can effectively diminish health disparities, and that community life—and human lives—are better off when it can be achieved. Yet, significant barriers continue to stand in the way of integration, including isolated government departments, data systems that rarely “speak” to each other, and siloed funding sources—all of which have emerged organically over many years.

To better understand the current state of health and human services integration across the United States, the Kresge Foundation and the Center for Healthcare Research and Transformation (CHRT) at the University of Michigan embarked on an exploration of integration efforts across the country. We tracked the goals of these initiatives; the groups, systems, and programs that had been integrated; the factors that proved critical to success; the outcomes for those who are the most vulnerable (populations such as youth at risk, seniors, and those living in poverty); and, importantly, we recorded the challenges and lessons learned along the way.

Inspirational Leaders

The integration leaders who oversaw these initiatives—leaders of agencies like the Arlington County Department of Human Services, in Virginia; the Cuyahoga (County) Tapestry System of Care, in Ohio; and the Boulder County Department of Housing and Human Services, in Colorado—were inspirational. They were skilled navigators of complex cultural, political, and policy environments. They were mission-driven, persistent, and deeply collaborative. They were strategic thinkers with a process orientation. They were adept at patching together funding from a variety of sources including foundation grants and government funds. And their communities, and the populations they served, were better for it.

We spoke with Uma Ahluwalia, for example, who has led a number of transformational integration initiatives during her eleven years of service as director of Maryland’s Montgomery County Department of Health and Human Services. Ahluwalia spoke about the “no wrong door” service philosophy that continues to inspire her work. But while she believes that it’s inhumane for clients to have to tell their stories over and over again to apply for and access the services they require, Ahluwalia also discussed the complexity of managing 120 programs, 120,000 clients, 1,386 full-time staff members, and 640 community partnerships—with critical data scattered across dozens of local, state, and federal databases.

Recently, the Montgomery County department that Ahluwalia directs launched an enterprise integrated case management system that connects 1,600 staff and forty different programs in the department. The new system, which took a significant amount of time and resources to develop, of course, is now allowing staff to capture case information from multiple programs (mental health, substance use treatment, and more) and to generate client referrals across all forty programs. In the department’s 2017 annual report, Ahluwalia said that “the exciting work of using data to manage our programs and track our outcomes is beginning,” but she also acknowledged that while the department had “much to be proud of,” it had “still more to accomplish.”

The Nine Lessons

Through case studies and interviews with Ahluwalia and other leaders across the country, nine important lessons for health and human services integration emerged. Here, we share these lessons and talk about why the grantmakers that care about integration—as the Kresge Foundation does—need to understand them, too.

1. Engage the community and clients. The integration of health and human services is all about better serving clients with complex needs. Integration efforts that only engage agency staff aren’t nearly as strong as those that involve the community and clients served. Effective outreach efforts are needed—such as community forums, summits, stakeholder surveys, and interviews—to understand priorities and challenges.
2. Start small. Buy-in, trust, and culture change among staff from different agencies are critical to achieving integration. Leaders often start small, such as by collaborating on a single program (for example, homeless services) and work from there. Program integration identifies shared goals and builds trust among staff from different agencies, forging a strong basis for systemswide and agencywide integration efforts.
3. Take time to plan. While an integration plan should be flexible and responsive to local conditions and environmental changes along the way, it should be in place from the beginning to avoid significant delays and budget overruns. If an integration initiative is already in process, take time to develop a plan anyway—it will help with future development.
4. Use a phased approach. Integration cannot be accomplished successfully with a “big bang rollout.” Integrating one sector of a system can change the functionality of another sector, and new policies, challenges, and opportunities will inevitably crop up along the way. With a multiphase integration plan and ongoing evaluation, leaders will have the time they need to address challenges and opportunities along the way.
5. Collaborate and expand partnerships. Collaboration is more than just multiple organizations working to achieve a common goal. It is a way to foster new and important relationships, to expand capacity, to understand collective challenges, to secure new funding sources, and more. Investing time in collaborative activities establishes a platform for long-term success.
6. Partner with community-based organizations. Community-based organizations should be front and center when contemplating integration goals. They work directly with the populations being served, understand their needs, and know how to deliver services on the ground.
7. Communicate consistently. Throughout all phases of integration—from design through deployment—leaders need to update partners and welcome input, even from those not engaged in each phase, so that agency staff who are anxious about changes know that these partners are actively involved in the evolving integration initiative.
8. Involve field staff. Leaders should engage staff from public agencies in the conversation about integration needs and priorities. As practitioners, staff know the challenges to integration and the resources they’ll need to accomplish the objectives. Disinterested third parties can help to facilitate these conversations in an inclusive and transparent way.
9. Develop solid business processes. A deliberative process for managing change is essential to ensure that data can be shared across systems and programs and that work flows are effective. New administrative requirements, with limited time for staff to learn about them, and inaccessible data can increase overall personnel dissatisfaction and reduce effectiveness. Business processes that support capacity building and training on new technology improve staff morale and overall operational efficiency.

The Case For Philanthropy

Leaders like Ahluwalia have shown that health and human services integration can be achieved, that there are key steps to success, and that integration can and does improve outcomes for those with the most significant needs, but these leaders can’t do this work alone. We believe that funders, and foundations in particular, must be partners in the process, helping local leaders overcome the many and complex barriers to integration.

To this end, the Kresge Foundation has recently launched a new focus area in its health portfolio that is designed to help health and human service leaders create more seamless, effective, and sustainable integration systems. The goal: To advance social and economic mobility and to improve health, health equity, and the well-being of children and families. The foundation plans to support organizations that are working to move beyond collaborative programming to more integrated practices, policies, and financing.

Integration takes time and effort. Those leading system change efforts are unlikely to overcome all of the cross-sector organizational barriers within limited grant cycles. However, leaders can be inspired, educated, and resourced to advance and develop system improvements so programs are more accessible and useful to the families they serve—which is well worth the investment.

Other funders interested in health and human services integration include the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation.

Related Reading:

“Integrating Medical And Social Services: A Pressing Priority For Health Systems And Payers,” by Melinda K. Abrams and Donald Moulds of the Commonwealth Fund, July 5, 2016, GrantWatch section of Health Affairs Blog.