Canada
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If major weaknesses in social care systems weren’t already well-recognized, the COVID-19 pandemic made them abundantly clear. The pandemic displaced a large number of workers, particularly in the sectors hit hardest by shutdowns. As many as 100 million workers across the United States, China, France, Germany, India, Japan, Spain, and the United Kingdom may need to find new occupations by 2030.1 A study commissioned by the United Nations found that, due to the pandemic, women and children around the world lost access to 20% of the health and human services they formerly received.2 Homelessness, food insecurity, social and economic disparities, and digital access divides have all been exacerbated by the pandemic. The pandemic has put enormous pressure on social care systems, and there’s no clear sense yet of when—and how many—lost jobs may return. This emergency has prompted a growing consensus on the need to reform social care.
But these troubles didn’t begin with the pandemic. Aging populations, increased prevalence of disability and mental health issues, rising inequality, and the growth of automation, among other pressures, have strained human service ecosystems. Even in recent years of economic expansion, many workers found themselves stuck in jobs that paid little and provided few or no benefits and turned to social care agencies for help with basic needs.3 According to the U.S. Private Sector Job Quality Index, as of July 2021, for every 81 Americans working in “high-quality” jobs—those with relatively high wages and high numbers of hours worked—100 were working in “low-quality” jobs, a marked fall from the prerecession ratio of 90:100.4 Across the Atlantic, job quality in the European Union also has declined since the post-2008 financial crisis.5 In European nations including France, Germany, and Spain, low-wage workers account for 47% of the workforce and almost 60% of workers displaced in a post–COVID-19 economy.6
Today, the core elements of the social care system—all the programs and services that fall under the traditional human services umbrella—no longer fit real-world needs.7 The basic contours of social care have been in place since the 1950s, when people could reasonably expect their jobs to support them for life. That social safety net generally served advanced economies well, but in the face of today’s environment it’s simply not fit for purpose. Although governments have tried to reform their social care systems in recent decades, they have overwhelmingly focused on making the existing systems more efficient or cost-effective. The current approaches look at the symptoms of social problems. What’s required for meaningful change is intervention that addresses the root causes—an approach that shifts focus from treatment to prevention, similar to what’s happened in health care.
Beyond small, scattered pockets of innovation, there’s been limited success in reshaping the basic framework of social care. Its structure has remained remarkably stable, due in part to the difficulty—inherent in all human systems—of relinquishing old orthodoxies and embracing new models. But that’s exactly what needs to be done. This means investing in the right things at the right time, focusing on early intervention, attacking problems at their root source, and creating paths to greater self-sufficiency and resilience. Doing so will require governments to transform the social care value chain. By value chain, we mean how governments identify and respond to the needs of those who require social supports—from needs identification and the evidence-based design of interventions to funding and the way in which services are delivered and evaluated. Our current value chains have remained static and are no longer able to respond to the evolving needs, increasing complexity, and comorbidities of our most vulnerable populations.
The current approaches look at the symptoms of social problems. What’s required for meaningful change is intervention that addresses the root causes—an approach that shifts focus from treatment to prevention.
With economic insecurity on the rise, the social safety net has been stretched perilously thin—and the rise of automation signals that it will be stretched thinner yet.8 Many governments can’t afford to fund their social care systems at the scale needed without sacrificing other important priorities.
The overarching goal for social care in the future must be resilience: investing in communities, natural networks of care, and society’s ability to survive future shock.
New solutions for our current social challenges do exist. The world is on the cusp of a major transformation in social care. Most of the preconditions for change are present today, their advent accelerated by the pandemic.
This report presents a vision for the transformation of social care and the qualities that can help meet society’s important challenges, today and in the future.
Orthodoxies are deeply held beliefs about how things should be done. They often take the form of standard practices that help individuals and institutions function more efficiently. But they also can produce dogmatic resistance to change and blind spots that can prevent the development of new and better methods.
The pandemic has challenged many orthodoxies—whether it’s the notion that certain services can be only delivered in person, or that work must be done in offices from 9 to 5—and shown that letting go of the norm can unlock new opportunities. To help ensure the social safety net serves the needs of today’s vulnerable populations, governments must upend old orthodoxies about how social care systems should be designed and funded; who should deliver assistance; and how programs should be measured and evaluated.
New ways of thinking about social care are challenging governments to create greater mission value, develop cultures of innovation, and create a better, more human experience for citizens, organizations, and their employees (figure 1).
These new orthodoxies can help governments to approach the core components of the value chain differently. They provide governments with an opportunity to revisit their social care approach. They help put families at the center of service delivery strategies, prioritize funding to support resilience in individuals and communities, and use advances in evaluation and measurement to hone program design.
Together, these approaches will require us to reconfigure operating and delivery models at three levels—system, provider, and client—to yield an approach that is integrated, preventative, and family-centered.
Today, many governments recognize the need to enhance the way in which they procure, manage, and support complex human service ecosystems. We’re starting to understand how the entire social care value chain should evolve to meet current and emerging challenges. Among governments making progress toward transforming their social care systems, several leading practices have begun to emerge. These practices constitute a set of principles to reconfigure the value chain for the future.
Government-run programs can keep incipient issues from erupting into major problems if they take a holistic support approach, one that considers multiple, interconnected needs. Most social care programs today provide symptom relief in the form of temporary assistance and benefits. These are helpful and necessary—and in some cases, they’re all an individual or family may need to get them through a rough patch. But they rarely attack problems at the source or address the connections among multiple challenges. To make lasting and meaningful progress, agencies should consider physical, mental, economic, and social needs, and overall well-being. Basic needs such as housing, food, and safety make a big impact on health—and the use of health care services.
Many health care providers have started to screen patients for social determinants of health and then refer them to appropriate resources. New York City Health + Hospitals piloted such a program in 2017. Its screening tools cover critical domains (food insecurity, health insurance coverage, housing concerns, public income benefits, household interpersonal violence, adult education and literacy, daycare, and general and immigration-related legal problems) in which patients can access government- or community-based resources.9
One tool that can support the holistic and preventive approach is an internet portal connecting citizens to a broad range of resources, curated to fit their individual needs. Community resource engines can suggest packages of complementary resources so that residents seeking help with housing, food, employment, or other issues can see their full range of options. Such systems can track users’ social determinants of health, give community partners tools to manage referrals for their services, provide caseworkers with a way to collaborate and coordinate care, and allow residents to provide feedback on their circumstances.10
Holistic approaches produce better outcomes while saving money for the social care system. A good example is the Nurse-Family Partnership, a Denver-based nonprofit that arranges home visits by registered nurses for low-income, first-time mothers. The program, which has partnered with several Medicaid agencies, is designed to improve pregnancy outcomes and children’s health, and encourage economic self-sufficiency. Years of trials have documented a 48% reduction in child abuse and a 61% reduction in arrests of mothers, as well as an 82% increase in the time mothers spend in gainful employment.11 Every dollar invested in the Nurse-Family Partnership saves the federal government more than US$5 in future costs for the highest-risk families.12
The studies used to evaluate the Nurse-Family Partnership illustrate how data and evidence can guide government organizations to the most effective solutions for social care. Evidence about performance should inform agency decisions, while real-time data on client outcomes and system performance allows agencies to “fail and learn quickly” as they innovate. Best practices emerge, practitioners share them, and the community scales them up for widespread use.
But what happens when there’s too much evidence? The strategy meant to help becomes a hurdle, as agencies simply lack the time or resources to process program information. For evidence to be useful, it has to be actionable.
US-based firm Mission Measurement is a world leader in social outcomes measurement and has pioneered innovations in digital, evidence-based outcomes measurement. The Impact Genome Project® (IGP) is a pioneering database technology platform that standardizes impact data and makes it actionable. By standardizing data, the IGP makes possible benchmarking, prediction, and evidence synthesis.
IGP is based on the theory that, despite the seemingly infinite differences among social programs, most share similar DNA, identifiable program design features, or “genes.” Program genes can be standardized, coded, quantified, and analyzed. By creating standardized and comparable data, IGP can help answer questions like: “Why do some programs work better than others?,” “What can we learn across multiple studies and programs?,” and, “How can you compare two different programs?”
The goal of IGP is to help solve social problems more effectively. The power behind the IGP is standardization. Standards make comparison possible. And comparisons enable benchmarking and innovation. Standards, benchmarks, and innovation can have a powerful effect on public policy and philanthropy: it can level the playing field, unlock the evidence base, democratize the tools of evaluation, rationalize resource allocation, and, potentially lead to more effective and efficient solutions to social problems.
Evidence about performance should inform agency decisions, while real-time data on client outcomes and system performance allows agencies to “fail and learn quickly” as they innovate.
Governments seeking to transform social care also need to look beyond the numbers. After all, social care programs are created and delivered by people to benefit people. A human-centered mindset is essential to transforming the social care value chain.
Human-centered design (HCD) puts people—their beliefs, values, feelings, and ambitions—at the center of the design and delivery of public policies and programs. HCD turns traditional problem-solving approaches upside down. Instead of defining operational goals and then fitting them to client needs, HCD begins with an effort to understand key stakeholders and identify the root causes of their problems. Once these unmet needs are understood, the resulting insights can be used to improve service design and delivery (figure 2).
In social care, HCD considers the human experience of the organization’s workforce and partners as well as its clients. The design approach brings the end users into the room with providers, caseworkers, and other stakeholders to engage in rapid prototyping, testing, and iteration of solutions. This deep collaboration can accelerate the development and rollout of solutions while creating room for early experimentation. The design team can jettison unworkable ideas and test viable solutions quickly before making costly investments in infrastructure and production.
Solutions developed using HCD hit the sweet spot: They’re desirable, because they meet stakeholder and user needs; they’ve been tested and proven to be technically feasible; and they’re financially and organizationally viable, meeting business requirements (figure 3).
Social care agencies are beginning to use HCD in many programs. For instance, the US Medicaid program has used HCD to consider the factors that keep members from renewing their benefits, thus losing their health coverage. Labor departments have used HCD to understand the experience of persons applying for unemployment benefits, eliminating opportunities for error and thereby reducing the burden on caseworkers. Child support agencies have used it to better understand why some parents struggle to meet their support obligations and to find creative opportunities to help them.
In Kentucky, the state used HCD to figure out why many individuals who are eligible for the Supplemental Nutrition Assistance Program Employment and Training (SNAP E&T) program fail to use it. Researchers spent four weeks interviewing 58 people, including SNAP recipients, agency employees, and partners. Among other conclusions, they found that many recipients find it difficult to comply with the program’s requirements; the jobs they secure may meet immediate needs, but don’t match their long-term interests or ambitions; and many recipients fear that a new job will disqualify them for benefits without fully covering their needs. Kentucky used this information to develop a new communications campaign to help participants make better use of SNAP E&T and help staff and partners better address participants’ actual needs.13
Despite its advantages, the HCD approach is only just beginning to take hold in social services. To spread its adoption, agency leaders should dispense with old notions about “the way things are” and begin seeing things from the customer’s perspective.
Procurement practices should also change. These often require an agency to predefine its problem and spell out the scope of work that must be performed. Yet this process is antithetical to HCD, which assumes that participants will do a good deal of exploration before they determine the solutions they need. Agencies should consider breaking procurement into two steps, starting with research to develop a vision and a set of strategies and then moving on to implementation.
Social care programs should serve as stewards for the entire care ecosystem, fortifying natural support networks. Extended families, faith communities, local nonprofits, and neighborhood groups, among others, can provide important support to individuals and families, and government should embrace and invest in them.
The United States, Canada, the United Kingdom, Australia, and many other nations support unpaid caregivers who look after loved ones, providing them with financial allowances or tax credits. They also provide grants to local and community groups that train and assist caregivers. Doing so can help caregivers remain engaged in the community, participate in the workforce, and stay healthy while performing their duties.
Family relationships have a significant influence on a person’s well-being. Family and natural supports (FNS) programs focus on strengthening relationships between young people and adults who care about them—a parent, grandparent, aunt, uncle, sibling, neighbor, teacher, or coach—through counselling, mediation, or skill-building. Good relationships with the right individuals can keep young people connected to schools and communities and create networks they can draw upon throughout their lives.14
Canada’s “Without a Home” Study—its first national survey of young people experiencing homelessness—found that more than three-quarters of those surveyed cited poor relations with their parents as a key reason for leaving home. It also found that a majority of them were in contact with a family member at least monthly and wanted to improve their relationships with their families.15 Covenant House in Toronto operates an FNS program that offers intensive clinical support and case management to help young people reconnect with family members safely.16
By supporting programs that build relationships within the community, governments can strengthen the role of informal networks in the lives of those who need care. Community-building can combat loneliness and isolation, often precursors to more complex issues such as dementia, stroke, heart attack, and mental health problems.
By supporting programs that build relationships within the community, governments can strengthen the role of informal networks in the lives of those who need care.
In the United Kingdom, the nonprofit organization North London Cares organizes community networks of young professionals and older neighbors who help one another reduce loneliness and isolation while improving neighborliness, well-being, skills, and emotional resilience across social, generational, and cultural divides. In 2016, a program evaluation found that participating neighbors felt healthier, happier, and more engaged in the community, and that more older neighbors indicated they had others to rely on when they had problems.17 To fight the isolation brought on by the pandemic, North London Cares started a “phone-a-friend program” that matched pairs of neighbors stuck at home for weekly check-ins and chats.18
As community-led care expands and matures, government agencies can shift their focus to stewarding a broader social care ecosystem, giving communities and families resources they can use to care for themselves.
Governments should explore measures to create a personal budget model that empowers seniors to access the care they want. Doing so can help ensure that the senior-centric ecosystem recognizes that the care needs and desires of seniors will vary. Under a personal budget model, funds would be means-tested and allocated on the basis of need. In Canada, for example, at the federal level, this would include maintaining the government’s commitment to increasing Old Age Security and the Canada Pension Plan survivor’s benefit.
Source: Deloitte, “Making Canada the best place in the world to age by 2030: A senior-centric strategy.”
Social care agencies should put outcomes at the center of program procurement and evaluation. Governments shouldn’t measure their progress by the number of interventions or services they provide. Of course, output measures do matter, and should be tracked to assess the timeliness and accuracy of service delivery. But to truly improve the well-being of families and communities, social care must focus on outcomes. Agencies should apply the outcomes-based approach throughout the social care value chain, from design and procurement to delivery and evaluation.
To truly improve the well-being of families and communities, social care must focus on outcomes.
The outcomes approach has become more popular in recent years, but it’s still relatively uncommon. Most programs still use metrics that focus on processes, tasks, and outputs (e.g., checks issued, referrals made, etc.), rather than the quality of engagement and tangible improvements in the lives of those they serve. Inflexible timescales and the pressure to accomplish more with fewer resources also make it hard to move from an output mindset.
In the United States, the state of Oregon uses data integration to more fully understand and compare the impact of its programs and services on children’s lives. The Oregon Child Integrated Dataset securely combines and analyzes data from five state agencies—the Department of Education, Early Learning Division, Department of Human Services, Oregon Health Authority, and Oregon Youth Authority—to identify opportunities to better support positive outcomes for children.19
Wales has a national outcomes framework that describes how it will measure improvements in care and support services. This framework considers personal outcomes, improving well-being by understanding what matters to people and what they want to achieve.20 For example, a person might want to find stable employment, regain their independence at home after a hospital stay, or reconnect with estranged parents.
By acknowledging people’s goals and aspirations and giving them some control over their care, providers can help them find the best path forward. Scotland’s Self-Directed Support program, for example, gives beneficiaries a budget to plan their own services as equal partners with social care staff.21
Agencies can also focus on outcomes in procurement and contracting. Rather than designing a contract that funds a specific number of workshops for domestic violence survivors, for instance, an outcomes-based approach would require a provider to show fewer repeat cases of domestic violence among its clients as a result of its work.
In the United States, Rhode Island’s Department of Children, Youth, and Families (DCYF) has made significant strides in outcomes-based contracting. In 2016, DCYF completed a procurement cycle that resulted in 116 new contracts organized around 15 outcome-based service categories tied to specific objectives. The contracts asked providers to propose programs to help children and families achieve specific outcomes; this flexibility allowed local experts and providers to offer ideas DCYF hadn’t considered before. Since this procurement cycle, DCYF has seen a 66% increase in its number of contracts with family-based foster homes and a 23% reduction in its share of foster children living in group settings.22
Social care agencies tend to capture data on problem areas, such as lost jobs, criminal convictions, homelessness, and hunger. They rarely seek data about what’s going well for individuals or communities. Little attention is paid, for example, to how many elderly people get to medical appointments with help from volunteer drivers, or how many previously unemployed people find stable, well-paying jobs. But a government that wants to improve people’s lives needs to understand community strengths.
Strengths-based data collection considers community assets and the positive aspects of people’s lives. Shifting the focus to “what’s right” can identify untapped or underused community resources and assets. It helps to nurture resilience rather than dependency.
In one strengths-based approach called asset-based community development (ABCD), social care agencies identify people with specific talents and resources and connect them with complementary needs. The idea is to build on strengths already in the community, focusing on what residents can do for one another. In the United Kingdom, for example, as part of the York City Council’s ABCD program, one resident who overcame serious health challenges now serves as a community health champion, arranging activities that foster relationships among people in her community.23
ABCD advocates point to five kinds of assets found in every community—people with skills and abilities; associations formed to achieve common purposes; institutions such as businesses, schools, and government organizations; physical assets such as land and the built environment; and connections among individuals. Programs based on ABCD harness these assets to improve the social determinants of health in their community, using social capital—the level of connectedness among residents—to drive changes that improve well-being for everyone.
In Whitesburg, Kentucky, for example, a community partnership called the Letcher County Culture Hub builds on local assets to improve community capacity and wealth based on a model called community cultural economic development.24 This group has helped start new local businesses and expand others; helped local artists, farmers, teachers, and others use their skills to generate revenue; and revived two local, moneymaking cultural institutions, a square dance, and a bluegrass festival.25
Large-scale change often requires a watershed moment, one that forces us to acknowledge and accommodate a new world order. The Great Depression was one such example, giving rise to the New Deal. The September 11 terrorist attacks were another, transforming international air travel and national security. COVID-19 and its associated costs represent another such moment, one with the potential to reshape health and social care systems.
Various jurisdictions have advanced many of the concepts behind the new social care value chain, but it’s occurred in a piecemeal fashion. The new orthodoxies have yet to take root across all levels of the social care system (figure 4). When they do, here’s how a holistic ecosystem of care will take shape:
On the system level, the social care system will provide oversight and stewardship across the entire client journey, with support from robust outcomes-based data. Connected information systems will support integrated case management, collaboration among provider networks, and seamless care journeys.
On the provider level, agencies and provider partners will be integrated across disciplines, with funding models that enable collaborative partnerships. This model will encourage holistic care plans and care teams supported by data-sharing and case management systems.
On the client level, the system will tailor a unique care plan to fit the needs of each client.
To create this new ecosystem, social care agencies should transform their entire value chain. They can start with policies grounded in a human-centered approach and evidence-based decision-making. They’ll use HCD to develop a service portfolio, adopt agile and flexible sourcing strategies, and develop a menu of funding models for different situations. Oversight will focus on evidence-based delivery models, while regulatory regimes will break down systemic barriers to create diverse and inclusive ecosystems. To evaluate the quality of services, agencies will continually measure the real-world impact on the people who receive them.
With this new vision for social care ecosystems, leaders must invest in factors that enhance outcomes across the social value chain, including data governance and integration, case management, security, technology, digital abilities, and workforce (see sidebar, “Social care ecosystem enablers”). While these factors are crucial, however, none will ensure success unless leaders have the will, the mandate, and the capabilities to drive the transformation.
Data governance and integration
Case management
Security
Digital
Workforce
The pandemic has presented a once-in-a-generation opportunity to trade traditional approaches for innovative models that engage broad networks of diverse stakeholders, all working toward a shared vision—a social care system designed for today’s needs.
The authors would like to thank William Eggers, Adithi Pandit, Anita Ghose, Rebecca Hildebrand, Caroline Hope, Phong Huynh, Jitinder Kohli, Paul Macmillan, Beth McGrath, Stefan Seltmann, Kate Smucker, Anthony Stephan, Susan Sterling, Mathieu Van Bergen, Eric D’Agostino, Jack Maher, Katharina Wolff, Alexis Martin, and Alyssa Zachmann for their inputs to this article.
Cover image by: Alex Nabaum
