How this Works > Field and Sector Implications

Sustainable Outcomes Require an Interdependent Web of Strategies

By Susan Dreyfus

All of us who have been on the funding side of human services want to know that the public, private, or philanthropic dollars we spend are delivering real outcomes that help people reach their fullest potential. However, a mistake we frequently make is to think that the solutions are simply linear and technical in nature. For example, we focus on implementing a values-based payment methodology for a specific program or service, or require evidence-based interventions. Both are pieces of the puzzle, but in and of themselves won’t produce the desired results. To improve the human condition is an adaptive challenge that requires adaptive solutions. For too long, we have focused our quest for outcomes solely on funding a program or service to be delivered, and not on unpacking the necessary capacities that must sit at the foundation of an organization’s ability to implement its programs and services with fidelity and affect the context within which people live their daily lives. No one program or service can accomplish that alone. If we continue to make this fundamental attribution error, we will not achieve sustainable outcomes for people and communities. Adaptive challenges must be recognized and understood for their complexity, and adaptive solutions must be developed, implemented, and funded.

A great example of this is Wraparound Milwaukee. Having operated over the past 21 years, this proven evidence-based model has been implemented and replicated nationally and internationally across many different disciplines to positively change the trajectories of young people’s lives and achieve measurable results. The blended, capitated, risk-sharing reimbursement and flexible payment model allows for money to follow the people being provided with services and supports “wrapped around” their needs and strengths. At the same time, the funding strategies also sustain and support the costs of the necessary infrastructure that Wraparound Milwaukee must have to ensure quality staffing, a robust and effective network of providers, innovative data systems, continuous quality improvement, and recognized community leadership and effective advocacy. The money it has saved through reduced need for institutional placements, such as unnecessary hospitalization and lower cost per recipient of services, has been reinvested back into the program to serve additional families. Wraparound Milwaukee has come to understand that achieving outcomes isn’t just about effecting positive change for an individual youth and family, but about creating changes that improve the system of care for the entire community. We must seek to understand and listen to families and consumers and positively influence these factors when they are barriers to families’ ability to lead safe and healthy lives. Put simply, the social determinants of health are the social determinants of life! Safe and suitable housing, transportation, employment, education, and access to integrated health care are among the areas on which Wraparound Milwaukee must focus its attention because these factors and others affect our ability to achieve positive outcomes for families and help at-risk youth move forward in their lives with greater promise, hope, and resilience.

The key to achieving outcomes-based funding models is to understand what it truly costs to realize the results we seek and equip organizations with the necessary capacities, competencies, and supports with flexibility and accountability. Often, payers do not understand the interdependent and complex web of strategies that are critical to the outcomes they claim they want to achieve. They want to fund what works, but the requirements they create resort back to the old fee-for-service, program-focused, micromanagement mindset that rigidly thwarts creativity and the ability to achieve and sustain meaningful outcomes.

If we are serious about tying funding and investment to outcomes, we need to understand that our grants and contracts must invest in the leadership and capacities of organizations. We should use our procurements to make sure that we are funding the best organizations and assessing their quality well beyond their ability to provide a specific program or service. This kind of funding would encourage experimentation and continuous quality improvement, as well as support organizations’ ability to partner and effect change in external and interconnected systems. As funders, we should work alongside these organizations to understand where current policy, regulatory, or fiscal constraints are influencing their ability to be successful, and work with them to bust those barriers. Would Fortune 500 CEOs keep their jobs if they were not continuously investing in the capacities their company must have to achieve desired results? Why aren’t we requiring organizations to state clearly the true cost of delivering the desired results and then comparing organizations accordingly?

I look forward to the day when an RFP comes out that requires organizations to articulate their adaptive capacities, along with the specific way they will deliver the desired program and service. Organizations should be required to clearly articulate how they are wired to authentically engage consumers; their generative governance; their capacity to use data and measurement for continuous improvement; their use of evidence and research; their staff development systems; their capacity to innovate; and their leadership, advocacy, and ability to partner deeply and effect change in the interconnected systems around them. How many more times will contracts go bad because we have not done our due diligence in differentiating between good and great organizations, or not funded great organizations for the very capacities and competencies that sit underneath and around their ability to be successful?

I learned this lesson in the late 1990s when I was administrator of children and family services for the state of Wisconsin and we implemented massive child welfare system reforms in Milwaukee County under class-action litigation. We redesigned the system to contract out by region to community-based organizations all services except child protective services and performance monitoring, which state staff continued to deliver directly. We identified the measurable goals we wanted to achieve and the child- and family-centered values on which the redesigned system was to be based. We wanted to see more children safe, able to live within their own families, and move children quickly to permanency in their lives.

But as I reflect back, I see that we implemented our contracts all wrong. We did what I continue to see government and other payers do today: We funded our contract partners for the direct-service staffing and service pattern we were expecting with little flexibility and no understanding of all the attributes of social-sector organizations we should have been leveraging. We did not understand all of the internal capacities these organizations would need to ensure quality, measurable, and sustainable outcomes over time. It’s time we acknowledge that the social sector is more than just providers of program and service under contract with others. Rather, it is made up of transformative agents within communities who provide their programs and services in a values-driven way — through their leadership, capacity to innovate, agility, partnerships, and paramount responsibility to advocacy and influence within the larger community. Lester Salamon, director of the Johns Hopkins Center for Civil Society Studies, says it well when he calls this the “distinctiveness advantage” of the sector.

I have never been more hopeful as I am today that we are finally moving from program thinking to systems-change thinking as a field and across sectors. The key now is to understand the adaptive challenge we face and have the courage to invest our resources in adaptive solutions.