Citation
Implementing integrated services

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Title:
Implementing integrated services individual and systemic responses to change
Creator:
Von Wald, Kristin Ellen
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
144 leaves : ; 28 cm

Subjects

Subjects / Keywords:
Integrated delivery of health care -- Case studies -- Colorado -- Broomfield ( lcsh )
Human services -- Case studies -- Colorado -- Broomfield ( lcsh )
Organizational change -- Case studies -- Colorado -- Broomfield ( lcsh )
Human services ( fast )
Integrated delivery of health care ( fast )
Organizational change ( fast )
Colorado -- Broomfield ( fast )
Genre:
Case studies. ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )
Case studies ( fast )

Notes

Bibliography:
Includes bibliographical references (leaves 139-144).
Thesis:
Educational leadership and innovation
General Note:
School of Education and Human Development
Statement of Responsibility:
by Kristin Ellen Von Wald.

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Source Institution:
|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
53378795 ( OCLC )
ocm53378795
Classification:
LD1190.E3 2002d V66 ( lcc )

Full Text
IMPLEMENTING INTEGRATED SERVICES:
INDIVIDUAL AND SYSTEMIC RESPONSES TO CHANGE
by
Kristin Ellen Von Wald
B.S., University of Colorado, Boulder, 1988
M.A., University of Colorado, Boulder, 1996
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Educational Leadership and Innovation
2002


2002 by Kristin Ellen Von Wald
All rights reserved.


This thesis for the Doctor of Philosophy
degree by
Kristin Ellen Von Wald
has been approved
by
Alan Davis
7- y-2003.
Date


Von Wald, Kristin Ellen (Ph.D., Educational Leadership and Innovation)
Implementing Integrated Services: Individual and Systemic Responses to
Change
Thesis directed by Professor Joseph Lasky
ABSTRACT
This study is the description of the implementation of an innovation,
in this case an integrated approach to providing services in a new county
health and human services agency. The purposes of the study are to
explore how the individuals and the systems respond to a proposed
innovation and to describe the evidence that reveals their efforts to develop
a new approach to providing health and human services. A qualitative,
case study research design was used to accomplish the purposes of the
study.
An integrated approach to health and human services attempts to
cross boundaries of funding, technology, programs, and populations to
provide services that are family-centered, outcomes-based, and
contextually oriented. Integrating public health and human services
requires reforms to existing systems in order to both effect and sustain
change. Creating a new county department of health and human services
in a new county is a rare and unique occurrence that provides an
IV


opportunity to create an integrated system of care for vulnerable individuals
and families.
Previous studies of integrated services projects have not included the
creation of a new county department within a new county. The results of this
study contribute a description of the change process and the efforts to
implement an integrated approach to health and human services across an
entire county agency while exploring the factors contributing to maintenance
of the status quo or progress toward change.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication. ~
Signed
v


DEDICATION
Though completing doctoral studies and dissertation research can be a lonely
undertaking, I was never alone in the process. There are many people to
whom I wish to dedicate my efforts.
First, and most important, to my husband, Phil, who values the pursuit of
excellence and education and is a model of dedication and discipline. He
gently prodded when I could not find motivation and provided refuge when I
needed safe haven. This thesis is the culmination of his staunch belief I could
and should pursue my passion and his tireless defense of my ability to do so.
To my children: Nicholas, who is preparing for adventures of his own, yet
never fails to be therebidden and unbiddenwhen his presence is most
needed; Lacey, who believes in me when I dont, and hugs me when I least
deserve it.
To my mother, Ruby, who is knowing and wise in ways that I will never be,
and to my father, Dick, whose fierce determination is my inspiration. Their
steadfast faith and love have nurtured me in every endeavor throughout my
life.
And finally, to the dedicated souls who labor to provide services to adults,
families, and children in all of our communities.
God bless.


ACKNOWLEDGEMENTS
Many people provided support, assistance, and encouragement throughout
my dissertation journey, and without them this dissertation would not have
become a reality. The following people deserve acknowledgement and my
heartfelt gratitude:
The people of the Broomfield Department of Health and Human Services,
whose generosity of time, energy, and honesty is not only the foundation of
this project but also the spirit of service to the citizens of Broomfield.
My doctoral dissertation committee, who provided necessary insight,
guidance, and reassurance that pointed this complex and difficult project
toward completion when it had the potential for growing out of control.
Dr. Marcia Muth and Jeff Roedel who provided valuable editing and writing
advice that helped me to become a better writer and to fine-tune this paper
into a product of which I can be proud.
And finally, the other students and faculty of the University of Colorado at
Denver, too many to name, who shared my journey and allowed me to share
theirs. I feel privileged to have crossed paths with all of you. Bon voyage,
fellow travelers!


CONTENTS
Figures.....................................................xiii
CHAPTER
I. Introduction ..............................................1
Setting for the Study...................................2
Phenomena of Interest...................................3
New Services......................................3
New Approach......................................3
Research Questions......................................4
Research Design.........................................5
Qualitative Case Study............................5
Researcher Propositions...........................6
Significance of the Study...............................6
The Case Study Report.................................. 7
II. Conceptual Framework For The Study........................9
Systems and Change.....................................10
Individual and Organizational Change.............11
Organizational Culture and Communication.........13
Integrated Services for Families and Children..........15
Vlll


Definition..........................................16
History.............................................21
Services Delivery and Systems Reform................26
Summary ...................................................30
III. Methodology ................................................31
Qualitative Approach.......................................31
Case Study ................................................33
Research Site, Participants, And Entry.....................33
Data Collection Methods and Research Routine...............35
Interviews..........................................35
Observations........................................36
Documents...........................................37
Research Routine....................................37
Data Analysis Methods......................................38
Validity and Reliability...................................40
Validity............................................41
Reliability.........................................41
The Researcher: Perspective and Roles......................43
Researcher Perspective..............................43
Researcher Roles....................................45
Approval, Confidentiality, and Informed Consent............47
IX


The Case Study Report..................................48
IV. Results 50
Context ...............................................50
The Place.......................................50
The People......................................53
The Time........................................54
The Task........................................55
The Vision ............................................57
A Work in Progress..............................59
Co-location.....................................61
Working Outside of HHS..........................64
Prevention......................................66
Its About the Clients..........................68
Implementing the Vision............................... 69
The Community...................................70
The City Organization...........................74
Funding.........................................78
Information Technology..........................81
The New Department..............................84
Work Groups.....................................97
x


The Generalist Approach.........................99
Summary of Results...................................102
V. Discussion And Conclusions..............................104
Results and Implications.............................105
Review of the Results..........................106
Implications...................................107
Leadership And The Management Team.............111
Recommendations................................112
Significance of the Study............................114
Limitations of the Research Design...................115
Recommendations for Further Research.................117
Summary and Conclusions..............................118
Appendix
A. Data Sources............................................121
B. Interview Protocol......................................122
C. Contact Summary Form....................................123
D. Coding Matrices........................................ 124
E. UCD Human Subjects Approval.............................126
F. Managers Experience And Education......................134
G. Vision And Mission Statements...........................135
H. Cornerstones............................................136
xi


References
137
xn


FIGURES
Figure
1. Services Integration Continuum
18


Chapter I
Introduction
Individuals and organizations are complicated and messy systems
existing in embedded contexts, interacting with each other to function as a
whole (Kauffman, 1980, p. 1). The more complex the system, the more levels
on which it functions, and the more those levels interact to preserve stability in
the entire system. Systems interact with information, respond to notices of
difference, and adjust to new information at different levels (Bateson, 1972).
Adjustments may be made that are expected and intended, and adjustments
may be made that are unexpected and unintended. Though information can be
introduced with the intent of changing a system, the system will function toward
stability, attempting to maintain the status quo. Even desired and anticipated
changes produce responseis throughout systems in an attempt to maintain
stability and to keep control (Wheatley, 1999).
Traditional health and human services are specialized, fragmented, and
categorical. The systems for services have evolved through decades of
practice, policy development, and funding and have grown more complex as
needs for services in communities have changed (General Accounting Office
[GAO], 1992; Kagan & Neville, 1993; Kahn & Kamerman, 1992; Konrad, 1996).
Integrated services is an approach to health and human services that crosses
1


boundaries of programs, funding, and populations for more efficient, effective,
and beneficial services for communities. Due to the complexity of systems
designed to serve communities, integrating services on a large scale and across
many program and funding barriers is difficult and rare (Schorr, 1997).
This study is the description of the implementation of an innovation. The
innovation in this case is an integrated approach to providing services in a
county health and human services agency. The opportunity to conduct this
investigation presented itself through the creation of a new health and human
services organization in a new county.
Setting for the Study
In a 1998 statewide election, Colorado voters approved a ballot initiative
allowing the City of Broomfield to become a city and county local government.
The citizens of Broomfield initiated the change effort to provide greater
autonomy and local control of the city situated within the boundaries of four
different counties. As a result of the approval of the initiative, Broomfield was
statutorily authorized to become a fully functioning county on November 15,
2001. Among the many other responsibilities of the new city and county is the
responsibility and obligation to provide health and human services for
Broomfield residents. The Broomfield City and County Department of Health
and Human Services is the setting for this study.
2


Phenomena of Interest
As a result of the creation of the new county, two changes are occurring
simultaneously: (a) creating a new department in a new county to provide
services previously provided by four different counties, and (b) attempting a new
approach to providing public health and human services.
New services
The new county must provide services that were previously the
responsibility of four different county systems. Though Broomfield residents
were served by the previous counties, it is believed that Broomfield residents
have been underserved and inefficiently served by those providers (Holeman,
1998). Four different agencies with different policies and politics in their
jurisdictions as well as a paucity of locally available, convenient services
fostered this belief. City Council memberswho also serve as County
Commissioners and the County Boards of Public Health and Human Services
have committed Broomfield to providing services specific to the needs of the
community, available and accessible in the community, and at least at the level
of services previously provided by the other counties.
New approach
The professionalization of the roles of service providers in the fields of
public health and human services has led to increased disciplinary
entrenchment in the education, licensing, and professional development of
3


practitioners. Psychologists, social workers, educators, law enforcement
officials, and health care providers are guided towards disciplinary mastery and
specialization by graduate schools, service providers, and system structures. At
the same time, trends in the policy environment support more collaboration and
coordination of services as the problems facing vulnerable individuals and
families grow more complex and cross more disciplinary boundaries. Integrated
services are an attempt to reform existing systems to obtain greater efficiency,
more cost effectiveness, and better outcomes for recipients through
interdisciplinary service provision (Garnett & Gould, 1996; GAO, 1992; Kagan &
Neville, 1993; Kahn & Kamerman, 1992; Knitzer, 1997; Konrad, 1996; Schorr,
1997). Based on community ideals, professional guidance, and trends in the
field, the local policy makers (ten city council members and one mayor) and city
staff (City Manager, Assistant City Manager, and the Director of Health and
Human Services) have committed to an interdisciplinary, collaborative, and
integrated approach to human services.
Research Questions
In this study, I describe the process of creating an organization that
will implement a new system for health and human services. My research
questions are as follows: How do the individuals and the systems respond
to the proposed innovation? What evidence emerges that reveals their
efforts to develop a new approach to providing health and human services?
4


Research Design
This investigation was conducted during an eight-month period chosen to
coincide with planning and implementation processes. It is intended to provide
insights into the issues and concerns of implementing an integrated services
innovation. This study is designed to be a descriptive and independent study of
a change process, not a personnel or program evaluation. However, the
implications of the findings presented here may prove valuable as others look at
implementing large-scale innovations in integrated services for families and
children or creating new systems for programs and services.
Qualitative Case Study
This study is a case study, bounded by the time frame, the single
research site, and the conceptual framework. It is a qualitative study, relying on
words as the primary analysis tool to describe the attitudes, perceptions, and
beliefs related to the phenomena of interest. Data were collected during a
specified time as the participants were engaged in implementing an innovation.
I adopted a participant observer stance and collected data through interviews,
observations, and documents. I used N*Vivo computer software for the coding,
sorting, and analysis of the data. Qualitative research strategies of triangulation
and member checks contribute to the reliability and validity of the results
presented.
5


Researcher Propositions
The research proposal and subsequent conduct of the research were
guided by researcher propositions. The propositions emerged from current
literature in the fields of systems change and integrated services, helped to
advance the study toward closure, and are reflected in the findings and
conclusions presented here (Creswell, 1998; Miles & Huberman, 1994; Stake,
1995). The researcher propositions in this case were that individuals and
organizations are systems that function to preserve stability, and the systems
involved in this innovation would respond to the innovation in ways that are
unanticipated and surprising to those involved in the process.
Significance of the Study
This study investigates the implementation of an innovation as it relates
to integrated services and systems change. The study contributes a rich
description of issues and concerns relevant to efforts to implement an integrated
approach to health and human services and an exploration of the factors
contributing to either maintenance of the status quo or progress toward change.
Creating a new county is a rare occurrence that presents a unique opportunity
to develop an integrated system for health and human services. An
investigation of this occurrence contributes to the knowledge base by describing
the process, the constraints, and the evidence of progress toward change.
6


The Case Study Report
Wolcott (1994) suggests that a case report be organized in a manner
that reflects the nature of the phenomena of interest. This case study
describes a change process, and the individual and systemic responses to
the innovation emerge over a period of time. Evidence that reveals the
participants efforts to implement a new approach to providing health and
human services does not emerge in a purely chronological fashion. The
evidence emerges around the issues and concerns of creating the
department and developing services as the participants activities and
attitudes cycle around and through the issues in a seemingly random
manner. The issues are interrelated and connected over time in complex
ways. The case study is dissertation research in partial fulfillment of the
requirements of a doctoral program. Thus the case study report is
presented in accordance with the customary five-chapter format of a
doctoral dissertation.
This Chapter I presents an overview of the study, the setting, the
phenomena of interest, the research design, and the significance of the
study. Chapter II outlines the conceptual frameworks that bound the study:
systems and change together with integrated services. Chapter III details
the methodology employed in the study, along with specific data collection
and analysis techniques and strategies for ensuring reliability and validity.
7


The results of the study are presented in Chapter IV, and the implications of
the results are discussed in Chapter V, along with limitations of the study
and suggestions for further research. Following Chapter V are the reference
list of all works cited and the appendices.
8


Chapter ii
Conceptual Framework for the Study
In spite of the best plans, we experience influences that we cant see
or test and strange occurrences that pop up everywhere. We all have
been forced to deal with unintended consequences of our well-
intended plans. We thought we were doing something helpful to solve
a problem, and suddenly we are confronted with eight new problems
created by our initial solution. There is no way to prevent these
troubling consequences. We can never do sufficient planning to avoid
them, because we cant possibly see all the connections that are truly
there. When we take a step or make a decision, we are tugging at
webs of relationships that are seldom visible but always present.
(Wheatley, 1999, p. 42).
This study is the description of the implementation of an innovation.
The innovation in this case is an integrated approach to providing services in
a new county health and human services agency. The research questions
are as follows: How do the individuals and the systems respond to the
proposed innovation? What evidence emerges that reveals their efforts to
develop a new approach to providing health and human services?
Along with the bounds of time and place, this case is bounded by the
conceptual framework. A systems perspective frames this study, and the
fundamentals of systems thinking (Kauffman, 1980) are an underlying and
overarching guide. Current literature related to systems and change are
presented together with literature related to integrated services.
9


This overlapping and intersecting framework describes the perspective
of embedded systems in organizations; describes the links between
organizational change, individual change, culture, and communication; and
presents the notion that integrating services requires systems change. The
purpose of the change effort is creating an integrated system of public health
and human services, which requires reforms to existing systems and changes
in the ways individuals operate. This conceptual framework served as a
guide for understanding the change effort as it progressed.
Relevant theories of individual and organizational change are
presented first, followed by a review of the literature related to communication
and change. The chapter closes with a review of the literature related to
integrated services from the dual perspectives of services delivery and
systems reform.
Systems and Change
The systems perspective considers the interrelated and interdependent
nature of all living systems. The systems perspective allows us to understand
we are not in control, we exist within a complex and connected whole, and
our deliberate actions often elicit unintended reactions (Bateson, 1972;
Clarke, 1987, Kauffman, 1980). In order to make sense of the world, human
beings have a tendency to fragment it, breaking it down into manageable
pieces and parts. Compartmentalizing is a way of perpetuating the illusion
10


that we are in control, unconnected to and uninfluenced by what happens
around us. The illusion is shattered by the unanticipated and unintended
consequences of deliberate actions and the surprising and unexpected
systemic responses.
Individual and Organizational Change
An individuals propensity for change is a direct reflection of how the
individual feels about, understands, and internalizes the impact of the change
(Covey, 1990; Evans, 1996; Fullan, 1993; Senge, 1990). There are recursive
loops between individuals, organizations, and environment, and these loops
interact with each other through reciprocal flows of influence. Living
organizations consist of embedded systems of individuals, work groups,
teams, divisions, departments, and community, all with permeable internal
and external boundaries that are influenced by information, energy, and
resource flow. The systems responses to these influences lead to actions in
the system, and the actions produce new responses (Bateson, 1972;
Wheatley, 1999).
Stephen Covey (1990) describes how personal change must precede
organizational change as organizations acknowledge and live by the values and
principles that guide individuals and human interaction. Fullan (1993) adds that
personal purpose is the route to organizational change__When personal
purpose is present in numbers it provides the power for deeper change (p. 14).
11


An important factor in implementing change is in recognizing what it means to
those who must implement it. Individual change does not guarantee
organizational change, however, without individual change no organizational
change occurs (Evans, 1996; Senge, 1990). Change efforts that ignore the
individual are unlikely to result in long-lasting, organizational change. From this
perspective, the most effective way to implement organizational change is to
effect individual change.
When a proposed organizational change conflicts with an individuals
sense of the world, the individual is unlikely to be receptive to the change. A
change force directed from outside the individual brings about more
dissatisfaction and resistance to change as the individual defends against what
may be viewed as a threat to an existing world view and familiar ways of thinking
and acting (Senge, 1990). The mindset, paradigms, mental models, and
framework of individuals must expand, shift, and be transformed to incorporate
new world views before change happens (Dean, 1997; Matusak, 1997; Senge,
1990).
All living systems respond to notices of difference, engaging in a
continuous process of organizing information to produce form (Bateson, 1972;
Wheatley, 1999). Processing information to create shared organizational
meaning elicits individual and organizational responses creating new information
and new responses. This process is iterative and recursive as living systems
12


continue to act on the notices of differences and the actions create new notices of
difference. Without this iterative and recursive process, without new information,
systems ultimately wind down and die (Wheatley, 1999).
Organizational change becomes possible by building a culture that
supports individual involvement in creating shared meanings and
organizational values (Bickham, 1996). Even individuals staunchly opposed
to participation in the work associated with an organizational change process
may participate if their individual needs, cares, and concerns are attended to
within the organizational system. A supportive culture reconstructs and then
reinforces new patterns of participation within the organizational system
(Bickham, 1996; Lambert et al., 1995; Mink, Mink, Downes, & Owen, 1994).
Through participation, more options become available, more information
flows, and more commitment is generated as many different perspectives
combine in the change process to notice new information and to create
shared meanings (Dannemiller & Jacobs, 1992; Wheatley, 1999).
Organizational Culture and Communication
Organizations are gatherings of individuals participating in the activity
of creating shared meanings and transmitting those meanings through
communication. Creating, maintaining, and recreating meaning among
organization members is the fundamental activity of organizations.
Communication of meaning provides the opportunity to create, recreate,
13


reinforce, and transform organizational structures, values, and operations
(Barrett, Thomas, & Hocevar, 1995). Communication creates meaning in
systems through patterns, redundancy, predictability, and information; and
systems operate on many different levels of communication and messages
(Bateson, 1972). Messages contain both content and form, and messages
are sent and received both explicitly and implicitly, creating flows of
information at many levels. Communication is carried out in formal and
informal ways, through official meetings and events as well as over coffee
and in small groups. Predictability, pattern, and ultimately shared meaning
emerge from the consistencies and inconsistencies of messages on many
levels.
The activity of communication in the form of language, building
vocabularies, and naming activities can become self-fulfilling. Language
creates the expression of what organizations are, and through language
meanings are shared and organizational reality is understood. What is
named becomes a reality (Thatchenkery, 1996).
Communication is embedded in and reflects the culture. It rises out of
the whole: language and mannerisms; selections of what to notice and what
to ignore; words that are chosen and words that are not chosen; the
messages conveyed in public, official forums, and the messages contained in
private, small group conversations. However, communication does not occur
14


until meaning is attached to the language, the mannerisms, the word choice,
and so forth. By paying attention to the meanings attached to both the
content and form of organizational communication, an organization may
ultimately create shared meanings that support learning, organizational
evolution, and change (Bushe, 2000; Clarke, 1998; Wheatley, 1999).
Integrated Services for Families and Children
Over the past three decades, literature in the field of integrated
services for families and children reflects an evolving definition of integrated
services and an emerging understanding of its future based on the
experiences of the past. Studies and evaluations of programs, demonstration
projects, initiatives, pilot programs, and reform efforts still provide scant
evidence of the benefits believed to be offered through services integration:
cost efficiency, improved outcomes for recipients, effective prevention and
early intervention, greater responsiveness to community needs, and
enhanced accountability. In addition, programs demonstrating integration of
services across disciplinary and institutional boundaries are seldom
successful at moving from small-scale to large-scale or sustaining changes to
services systems. Despite the lack of evidence and the lack of sustained
success, service providers and services agencies still advocate for more
integrated systems of service delivery, and funding sources still require
collaboration and coordination of services to be included in the projects they
15


fund. As integrated services projects attempt to achieve improved outcomes
for individuals and families, evaluations of these projects attempt to move the
field from advocacy based on beliefs to advocacy based on empirically
supported evidence.
The remainder of this chapter explores the literature relevant to (a)
defining the term integrated services, (b) outlining the history of the field, and
(c) providing distinctions between a services delivery approach and a systems
reform approach.
Definition
The struggle to find a clear definition of integrated services is evidence
of the greater tension to find clarity of purpose for programs that integrate
health, education, and welfare services. Many definitions of service
integration begin with defining the problems to be addressed. Others start
with outlining desired outcomes for individuals. Some definitions refer to
services integration as an outcome, and some refer to it as a process. Still
others define integrated services by what it is not, rather than what it is
(Kagan & Neville, 1993; Kahn & Kamerman, 1992; Knitzer, 1997; Konrad,
1996; Kuperminc & Cohen, 1995).
Virtually every services delivery or systems reform initiative advances
its own working definition of integrated services reflecting the perspective
from which the effort arises. Each definition takes on the nuances of the
16


agency, institution, or funding source, and reflects the linkages created,
problems to be solved, and/or outcomes to be realized. Human services
include health care, mental health services, education, social services,
juvenile justice, employment, public safety, services for senior citizens, and
childcare. With such a broad expanse of services, the opportunity for creating
service links and calling those links integrated services is substantial. The
integrated services umbrella covers any collaborative effort proposed by an
agency, yet the individual or a familys entry point into the system determines
the extent to which that individual or family actually experiences an integrated
services system of care (Kuperminc & Cohen, 1995).
Human services systems exist with varying levels of collaboration and
levels of intensity through dimensions on a continuum. The continuum spans
from informal to formal, from basic information sharing and networking
through full integration (Figure 1). A continuum provides a very broad and
inclusive range of definitions from two or more people or entities sharing
information and communicating through integration of funding streams,
authority, accountability, intake, information, and all other resources and
responsibilities (Konrad, 1996).
17


Informal
Formal


M
Information Sharing Cooperation and
And Communication Coordination Collaboration Consolidation
Integration
Figure 1. Services Integration Continuum (Konrad, 1996).
A definition of integrated services is required to differentiate it from
traditional human services. Some approaches tend to define integrated
services by articulating the problems in service delivery the effort is
attempting to overcome. In other words, if traditional human services can be
characterized as categorical service delivery, problematic to clients,
duplicative, fragmented, expensive, inefficient, unresponsive, unaccountable,
crisis oriented, and focused on professional interests rather than the clients
best interests (Konrad, 1996), then integrated integration should most
definitely not be those things. Definition of the term by saying what it is not
does not prove helpful in providing focus and purpose to what it could be.
Evolving work in the field of services integration highlights the need for
a more refined definition. Service providers recognize the problem of
integration is designing services that can address the interrelated nature of
the problems of at-risk individuals and families (GAO, 1992). Definitions for
integrated services should consider the multidimensional needs of the client-
recipients and the corresponding requirement for multidimensional responses
18


to those needs. They should also highlight both the systems and the services
approaches to integration. Kahn and Kamerman (1992) suggest that services
integration is an attempt to eliminate fragmentation and link individuals or
families with problems and needs to programs or providers that can address
their needs. It occurs through (a) administrative restructuring and
collaboration, or (b) case-oriented strategies at the service delivery level.
Kagan and Neville (1993) offer a definition that divides the services
integration framework into four synergistic dimensions:
1. service delivery or client-centered integration, where the focus is on
the client and the particular and various services provided;
2. program linkages or program-centered integration, with a focus on
linking together programs that serve the same or overlapping
populations or have similar or overlapping goals;
3. policy management or policy-centered integration, where the focus
centers around policy shifts and policy creation to accommodate
integration; and
4. organizational structure or organizationally-centered integration,
creating new structures and systems that support, encourage and
deliver integrated services.
The locus and focus of the services integration effort determines the
emphasis of the services integration strategy. Different domain emphases
19


will yield different results, all of which must be evaluated with greater
precision than blended and one-dimensional operating definitions allow. In
practice, the definition of services integration employed in an initiative
determines the perspective taken in establishing the purpose of the initiative.
The framework from which a services integration effort is viewed serves as
the guide for understanding, implementing, and evaluating the effort (Kagan &
Neville, 1993).
The descriptive definitions of services integration whereby the effort is
defined by the problems it will solve, the outcomes it will attain, or the values
it holds provides a general philosophical framework for services rather than
practical approaches to services. The term service integration serves as both
a broad critique of past approaches and an imperative for reorganizing those
approaches (Knitzer, 1997).
The struggle to define services integration reveals the struggle to
accomplish services integration. The use of a broadly defined moniker of
integrated services to describe programs anywhere on the continuum of
integration implies a loosely defined field of study with far-reaching
implications for future directions. It also implies an emerging understanding
of the breadth of purpose and enthusiasm that is indicative of a growing and
dynamic field of possibilities.
20


History
The integration of services is not a new idea. In fact, the notion of
community-based, comprehensive services for the poor dates back to the
colonial era when many new inhabitants of the American colonies were
deportees from Britainvagrants, felons, and the poor (Kagan & Neville,
1993). Community-based charity organization societies and settlement
houses provided the social services structure when friends and families could
not meet the needs of the poor. As demand grew, local communities turned
to colonial government for resources, thus establishing the colonial
government as a service provider (Kagan & Neville, 1993; Kahn &
Kamerman, 1992; Knitzer, 1997).
In addition to settlement houses, other historical efforts to provide
community-based, comprehensive services include parent education both (a)
on issues of health, nutrition, societal norms, parenting practices, and (b) for
purposes of increasing opportunity for the uneducated and immigrant adult
population. Community-based efforts increased with the formation of self-
help groups, beginning with the founding of Alcoholics Anonymous in the
1930s (Romualdi & Sandoval, 1997). From the 1920s through the 1960s,
economic challenges of the Great Depression and women moving into the
work force created an impetus for more government supports in terms of jobs,
health care, child welfare services, child care, and other social investments.
21


School-based health care and mental health services became
institutionalized. Problems of service fragmentation and duplication grew as
specialized programs were developed to address the overwhelming needs of
seriously troubled individuals and families. The Civil Rights movement
highlighted the need for an action agenda to address the needs of minorities,
women, and the poor while shifting emphasis to families as the focus of
intervention (Kagan & Neville, 1993; Kahn & Kamerman, 1992; Romualdi &
Sandoval, 1997).
The 1970s. Following the increase in activism and heightened
attention to issues of the disadvantaged and disenfranchised, the 1970s was
a decade of increased federal activity related to service provision and a
movement towards services integration. The U.S. Department of Health,
Education and Welfare secretary Elliot Richardson took the lead by calling for
systems reforms to break down categorical barriers and integrate services
across program areas (Konrad, 1996). Program expansion marked the early
1970s, with efforts to create super-agencies and broad-based human
services resources at the federal level. This flurry of activity was followed by
a reversal of program expansion in the late 1970s as Congress failed to pass
services integration legislation due in large part to pressure applied by
categorical services agencies (Kagan & Neville, 1993; Kahn & Kamerman,
1992; Konrad, 1996). This decade set the tone for future efforts by
22


highlighting the need for research and evaluation of programs. However,
federal funding still emphasized categorical service delivery; and resources
for evaluating the impacts of services integration initiatives on services
delivery or outcomes were not available. The 1970s began as a decade rich
in federally funded services integration activity in an effort to increase the
body of information related to improving services delivery systems. However,
the decade ended with funding cuts that effectively short-circuited the
opportunity to produce evaluations of programs that would contribute to
greater knowledge about the impact of services integration (Konrad, 1996).
The 1980s. As services integration initiatives began to lose
momentum at the federal level, state and local governments assumed the
agenda for providing human services. The federal government funded
services with block grants to the states in an attempt to increase service
integration, to reduce fragmentation and duplication, and to provide incentives
for local control and accountability for community-based service provision.
The change in focus was accompanied by reductions in human services
expenditures, so the opposite of what was intended actually occurred. As
categorical agencies fought for funding to maintain their existence, few were
interested in collaborating, coordinating, and reforming delivery systems
(Kahn & Kamerman, 1992).
23


To complicate matters further, the complexity of social problems and
the need for services was increasing at the same time social services
agencies were becoming less coordinated and cohesive as a system of
resources for troubled individuals (Kahn & Kamerman, 1992). New programs
and activities were initiated, but many of these programs were within
categorical systems rather than across systems. A growing emphasis on
academic standards and an accompanying understanding of schools as a
clearinghouse for overlapping and diverse family difficulties led to the
movement for full-service and community schools (Dryfoos, 1994; Konrad,
1996; Romualdi & Sandoval, 1997).
The 1990s. Reductions in funding at the federal level led to an
increase in the involvement of state and local governments, non-profit service
providers, and private foundations in funding for services. The role of the
federal government shifted to be that of a partner with foundations to provide
technical expertise for services integration. A focus on issues of students
readiness to learn and safety in schools continued to impact growing efforts to
provide school-based services and to build collaborative relationships
between schools, state and local governments, community agencies, and the
private sector (Dryfoos, 1994; Konrad, 1996). In addition, federal
requirements to provide special education services and services for
handicapped children raised awareness about the need for integration of
24


services through schools and partnerships between communities and schools
(Kahn & Kamerman, 1992).
Though activity in the field of services integration waxes and wanes
depending upon the tides of political interests and values in vogue, it
continues to gain momentum in practice as service providers see
opportunities to better serve the population of services recipients. While
services integration practices gain momentum, the accompanying call for
empirical evidence of the impact on outcomes, efficiency, efficacy, and
accountability has also gained momentum. Historical precedents of services
integration efforts contribute to the understanding that an assumption of better
service provision through collaboration and coordination is not enough. The
research must support services integration activity, and current efforts need to
address not only the impact of service delivery but also the impact of systems
reform. Including in such efforts appropriate measures, definitions, and
program evaluations to contribute to the field is necessary for continued
momentum in integrating services for families and children (Garnett & Gould,
1996).
Services Delivery and Systems Reform
In the field of integrated services, two related orientations have
emerged: services delivery and systems reform. Integrated services
initiatives often attempt to address both issues of service delivery and
25


systems reform, recognizing that it is rarely possible to innovate the one
without impacting the other. Systemic barriers and constraints to service
integration often prevent agencies from paying broader attention to systems
reform while still attempting to have a positive impact on outcomes for
individuals and families through direct service delivery. The challenges of
evaluating integrated services efforts include this tension between the
services orientation and the systems orientation. Simply put, if there is an
impact of integrated service delivery, is it attributed to the direct service or
program, or is it attributed to the change in the system? The context of
service delivery is as important as the service delivery itself (Garnett and
Gould, 1996; Knapp, 1995; Morrill, 1996).
In addition, innovations in research in the field of services integration
have lagged behind the movement. Methodology should include both
process and outcomes measures to move the focus beyond direct service
delivery alone toward an exploration of how innovations in service delivery
can lead to fundamental changes in the services system (Fredericks, 1994;
Garnett & Gould, 1996; lllback, Kalafat & Sanders, 1997; Konrad, 1996;
Kuperminc & Cohen, 1995; Morill, 1996).
The sentiment in service delivery remains enthusiastic towards service
integration across disciplinary, funding, and agency boundaries. However,
current services integration efforts are often within-category collaborations or
26


cross agency linkages rather than fully integrated and large-scale creations of
new delivery systems.
Services Delivery. The goals of services-oriented efforts include
establishing linkages between (a) clients and the various service providers to
meet the clients various needs, and (b) programs and agencies so services
can be improved. Services-oriented projects are generally smaller in scope
and have more modest goals. They include both formal and informal
agreements between service providers. Many of the projects address specific
problems like teen pregnancy, domestic violence, or identifying mental illness
in young children. Many programs offer services in schools, and are aimed at
improving school readiness or academic outcomes for at-risk children. The
measures of success of these services-oriented approaches are measures of
very specific outcomes related to that point of contact between service
provider and service recipient or the point of contact between agency and
program (GAO, 1992).
The reality for service providers is that they usually must respond to
the most immediate needs of their client. Many services-oriented initiatives
are in response to immediate need or crisis in a community. It is possible for
service providers to immediately link their clients to appropriate, relevant
services while having little impact on other issues that contribute to their
clients immediate need or the overall service delivery systems (GAO, 1992;
27


Garnett & Gould, 1996; Kagan & Neville, 1993; Kahn & Kamerman, 1992;
Schorr, 1997).
Community-based, wraparound, and prevention programs attempt to
link clients to existing services providers and empower individuals and
families to make decisions on their own behalf (Ray, Stromwall, Neumiller, &
Roloff, 1998). While these programs demonstrate success at the pilot site,
they most often fail when taken to scale or applied to larger populations of
service recipients. Services oriented approaches do not deal with larger
issues of systems reform and therefore can not withstand barriers inherent in
the systems when applied more broadly to different or larger populations
(Schorr, 1997).
Systems Reform. Successful services integration that can be
replicated, transferred to additional or different populations, and taken to
scale also require systemic changes in policy, program, staff development,
training, and funding (Garnett & Gould, 1996; Schorr, 1997; White &
Wehlage, 1995). In order to succeed and become institutionalized, however,
integration efforts on the service delivery level must be supported by policy
changes at the state level (Garnett & Gould, 1996). The systems reform
perspective also includes recognition that service recipients exist in context of
families, neighborhoods, institutions, and other societal systems. Addressing
the needs of individuals must include addressing the needs of families,
28


neighborhoods, schools, and communities in order to achieve better
outcomes (Crowson & Boyd, 1993; Knapp, 1995; Neill, 1997; White &
Wehlage, 1995; Zins& Wagner, 1997).
Even as services delivery approaches may experience more success
by attending to issues of systems reform, systems reform approaches must
attend to issues of services delivery to experience better outcomes (Bickman,
1996). The Fort Bragg demonstration project was a large scale continuum of
care study that looked at issues of implementing a comprehensive system of
care, evaluating the results, interpreting the findings, and determining whether
comprehensive services were effective and cost efficient. The Fort Bragg
Evaluation and accompanying literature analyzing and commenting on its
findings raise various issues of the services delivery and systems reform
approaches and the need for more and better research studies to inform the
field (Behar, 1997; Bickman, 1996; DeLeon & Williams, 1997; Feldman, 1997;
Saxe & Cross, 1997). The initial findings were that the integrated services
provided at Fort Bragg were more expensive, and they did not necessarily
result in improved outcomes for recipients. The interpretations, conclusions,
and recommendations of the authors who responded to the Fort Bragg
findings are widespread. The case draws attention to the issues of
methodology and analysis, and questions the values and beliefs inherent to
services integration philosophies. Before generalizations about services
29


integration and the viability of reforming systems for services can be made,
more studies of the scale of the Fort Bragg Evaluation are necessary.
Summary
This chapter presents a conceptual framework for the case study. The
framework describes the systems perspective, with emphases on the
connection between individual and organizational change, and the connection
between communication and culture. It highlights some of the issues and
contributions in the field of services integration. This framework served as an
initial guide for the study and continued to evolve as themes emerged from
the data. The following chapter details the methodology employed in the
conduct of this study.
30


Chapter III
Methodology
This research is a qualitative, single-site, case study design. I chose
this research strategy based on the descriptive and exploratory nature of the
study, the importance of the context of the setting, and the phenomena of
interest. This study is ethnographic in that I adopt a participant observer
stance, collect and analyze data over time, and look for evidence in
elements of organizational culture (Spradley, 1980). My approach also
reserved some flexibility by design in order to respond to the evolving
research process (Cresswell, 1998; Marshall & Rossman, 1999). The
setting for the study is a county department of public health and human
services and the participants are the individuals working in the department.
The phenomena of interest are the efforts to implement an integrated
services system for health and human services in a new county.
Qualitative Approach
A qualitative approach is the method of choice when the intent of the
research is to describe and explain attitudes, perceptions, and beliefs
related to complex phenomena from multiple perspectives while using words
as the primary analysis tool. Qualitative research is a holistic approach that
is appropriate when the phenomenon of interest is not easily extricable from
31


its context and when the desired product of the research is a description of
the meanings associated with a process (Cresswell, 1994; Krathwohl, 1998;
Merriam, 1988; Miles & Huberman, 1994; Stake, 1995).
Qualitative data provide a gauge of the meanings individuals assign
to behaviors, communications, and processes, as well as the connections
the individuals make between those meanings and the organizational world
they construct around them. Data collected over a period of time are
descriptors of the process of change and the creation of the organization.
Rich, qualitative data provide information about the system in close
proximity to the system as data are collected at the site and within the field.
Qualitative data are particularly well suited for providing descriptions and for
leading to explorations as new areas of interest develop (Krathwohl, 1998;
Marshall & Rossman, 1999; Miles & Huberman, 1994).
This study is ethnographic in that it seeks to describe the individuals
and systems responses to innovation as those responses are revealed over
time and in elements of the organizational culture. Data were collected
through interviews with the participants and observations by the researcher,
and descriptions of and inferences about the phenomena are presented in
this case study report (Spradley, 1980). The inferences are dependent upon
the context and inductive by design in that from the data themes emerge
and meanings are derived (Cresswell, 1998; Merriam, 1988).
32


Case Study
Yin (1993) states that a case study design is appropriate when it is
impossible to separate the phenomenon of interest from its context, and the
context itself may contain important information about the phenomenon.
The case study design bounds the phenomenon of interest and focuses
attention within the setting and the context. It is a method of framing the
study within a natural setting (Krathwohl, 1998; Merriam, 1988; Stake,
1995).
The case study design is appropriate here as the context of the new
organization and the phenomena of interest are inextricably linked within this
setting. This study is bounded in three ways: (a) by time, as it takes place
during the period from August 1, 2001, through April 1,2002; (b) by the
single research site; and (c) by the conceptual framework of individual and
systems change together with integrated services.
Research Site, Participants, and Entry
The research site is the newly created Department of Health and
Human Services in the City and County of Broomfield, Colorado. Though
part of the city and county system of local government, the Department of
Health and Human Services is physically located about one mile from the
main government offices.
33


There are six key research participantsthe director and five
managers of the departmentwho participated in the interviews and
attended the managers meetings where I conducted my observations.
Other staff members participated in the study on a more limited basis,
through their participation at staff meetings and conversations related to the
topic of this study. These other participants were identified because they
were either already employed by the department or hired during the
planning process and prior to the November 15 opening date. The only
participant attrition in this study was due to one of the core staff members
leaving the department in November to take a position in another part of the
city and county organization.
I gained entry to the research site through a series of conversations
over a period of nearly two years, first with the assistant city manager and
then with the director of the department of health and human services.
These conversations centered around the unique opportunity to document
the change process, particularly as it relates to the design and development
of an integrated model for public health and human services. I shared an
interest in the integrated model of services with the director of the
department. At the same time, the director defined a need for facilitation of
two community groups that would provide input into the development of
services. I offered to provide the facilitation. My request to do dissertation
34


research in the department, focusing on the topics of systems change and
integrated services, was granted by both the director and the assistant city
manager.
Data Collection Methods and Research Routine
Data collection began in August 2001 and continued through April 1,
2002. This time frame allowed for observations both before and after the
department opened to the public on November 15, 2001.
The research design anticipated multiple levels of interaction,
interpretation, and understanding between and among the participants.
Therefore I collected data on multiple levels through three primary means:
interviews, observations, and documents. The sources for data included in
this study are shown in Appendix A. In anticipation of the research design
yielding a magnitude of data, I employed a research routine to manage my
efforts and to keep track of the data.
Interviews
I conducted systematic interviews with the key participants. The
purpose of the interviews was to gather the participants reflections of their
expectations and experiences as they planned for and implemented
programs and services. I also wanted an opportunity to track the
participants perceptions of the change process. The interviews contributed
data related to the perceptions, beliefs, and attitudes of the individuals. I
35


made audio recordings of each interview and created a transcript of the
conversation. The interviews were also transcribed using N*Vivo computer
software for the purposes of data coding and sorting. The interview protocol
is shown as Appendix B and was used for both the first and second
recorded interviews with the key participants.
Observations
I collected data through participation in and observation of weekly
staff meetings, manager meetings, public meetings, and informal staff
gatherings. In addition, I spent time in the department and with staff
members fulfilling my responsibilities as a contractor and had many
opportunities to engage in conversations and observe daily activities. I took
systematic field notes while participating and observing and after contact in
the field. I transcribed field notes using N*Vivo for the purposes of data
coding and sorting. After each contactinterview, observation, or
conversationI used a contact summary form I created to summarize and
structure the field contact based on the interests of this study and to prepare
for future contact in the field (see Appendix C.)
Field notes and contact summaries include (a) specific quotes, the
person quoted, and the context in which the comments were made; (b) the
time and topics, noting the people speaking and the topics discussed, as
well as those not speaking and the topics not discussed; (c) the decisions
36


made, the process that led to the decisions, and the people involved; and (d)
any observable responses to the discussions and the decisions.
Documents
Data also include written documents, policies and procedures
manuals, and memos used or created by members of the organization. I
used a document summary form I created to review, summarize, and
analyze the documents. Early in my fieldwork, I found that the director
primarily communicated with the staff orally. In addition, written
communications often occurred via email, to which I had limited and
inconsistent access. For these reasons, though documents are included as
data in this study, I consciously prioritized what was said in interviews and in
observations over the information embedded in written documents.
Research Routine
The research routine was important in this study to manage the data
and multiple researcher roles. The structure I imposed includes the
following:
1. organizing my entry into the field each time by identifying the
nature of the contact and the issues to pay attention to during the
contact;
2. using field notes and contact and document summary forms to
record my observations;
37


3. taking time to summarize and to analyze the data as soon as
practical after it was collected; and
4. using a software program to store, code, and sort the
accumulation of data.
Adherence to the research routine provided structure and a
framework that contributes to the reliability and validity of the study.
Presenting the research routine as part of the data collection and analysis
processes presents the reader with a clear and accurate picture of the
methodology for this study (Cresswell, 1994).
Data Analysis Methods
Analysis of the data occurred on an ongoing and iterative basis from
the beginning of the study. I relied upon inductive analysis to lead to
findings of interest from the data and to modifications or additions to data
collection based on those findings (Merriam, 1988). Using N*Vivo, I coded
and sorted the data to discover emerging themes and trends so that those
themes and trends could be checked through additional data collection and
verification by informants (Miles & Huberman, 1994).
Cresswell (1994), Merriam, (1988), and Wolcott (1994), among
others, recommend essentially packing and unpacking the data in a
systematic manner so that redundant review of the data results in a
38


progressively clearer resolution of themes. My review and analysis of the
data included the following steps:
1. Reviewing field notes immediately following contact.
2. Completing a contact summary form for each interview,
conversation, and observation.
3. Transcribing field notes and recorded interviews into a computer
text file for later analysis using N*Vivo.
4. Reading the transcripts, choosing the interview transcripts as the
place to begin, and noting thoughts and ideas in the margins or on
a separate sheet.
5. Beginning a list of broad categories for the thoughts and ideas.
6. Clustering the categories around similarities and overlaps,
devising appropriate and distinct codes for identifying and sorting
the data.
7. Re-reading the transcripts with the notes, category clusters, and
codes; and refining the codes for insertion into the N*Vivo
transcripts.
8. Applying the coding scheme to the other data transcripts.
9. Adding new codes as new themes emerged.
Given the magnitude of data, this redundant and iterative analysis protocol
was necessary for appropriate and intensive analysis.
39


Based on my experience and knowledge of the setting, I expected to
find themes related to language and the construction of meaning; the
decisions that were made; the behaviors and actions related to those
decisions; and the emergence of procedures, routines, and cycles of activity.
I created a matrix based on these themes to use for sorting the codes as
they emerged while reading the data transcripts. Wolcott (1994) suggests
that even in the most descriptive of cases, some structure must be imposed.
The structure constitutes the first level of analysis, and the refinement and
revision of the structure is the iterative analysis and interpretation of the
data. I found that the original coding matrix was not very useful, so I
expanded and refined the matrix as the study progressed and themes
emerged (Miles & Huberman, 1994). The coding matrix and the list of codes
that evolved from data analysis is included as Appendix D.
Validity and Reliability.
While providing a rich, thick description (Cresswell, 1998) of the
change process, the multi-level research design allowed me to triangulate
findings and test issues of data validity and reliability. I describe this change
process and provide potential implications based on the data and the
conceptual framework. Evidence contributing to the descriptions and
implications was checked in different situations and with different individuals
over time to determine validity and consistency. Participants were asked to
40


review and comment on the descriptions of events and conversations. The
key informants were given a copy of the case study results and asked to
comment on the accuracy of the descriptions and interpretations. I did not
give them editing rights or privileges, but did listen to any concerns about
the descriptions and interpretations and, in a few instances, made
adjustments to the report in order to address their concerns. I also had
promised all participants not to include any information that they expressly
called off limits or off the record (Wolcott, 1994). The interviews,
observations, and document reports were combined to triangulate the data.
The member checks and triangulation contributed to the validity and
reliability of the findings (Goodwin & Goodwin, 1996; Krathwohl, 1998;
Lancy, 1993; Miles & Huberman, 1994).
Validity
With respect to validity, the issues are accuracy and consistency.
Accuracy is promoted by using tape recorders and making careful field
notes. Consistency is enhanced by clear operational definitions of the
concepts and constructs, and careful research techniques and routines. I
actively engaged in using accepted methods and approaches of the
qualitative tradition to ensure validity. I audio-recorded my interviews with
participants and then transcribed the recordings into a written record of the
interview. I took field notes and then transcribed those field notes into a
41


written record of the observation, event, conversation, or encounter. I also
summarized the field notes using a contact summary form. I kept track of
concepts and constructs, asking participants for clarification, and kept notes
of the operational definitions in use during field contact.
Reliability
With respect to reliability, the issue is providing descriptions and
explanations that systematically minimize bias through a fair and
comprehensive analysis of data. Reliability also has to do with
generalizability. Reliability is strengthened by thoroughly and carefully
describing the researchers role and the subjectivities inherent in the
researchers perspective. Through careful descriptions of all aspects of the
case and the research routines and strategies, the reader can determine the
extent to which any of the findings of this study can be generalized to
another setting or group (Goodwin & Goodwin, 1996). I again relied on the
strategies of triangulation and member checks to confirm or disconfirm my
observations and interpretations. Triangulation can be by data source
(which can include persons, time, places, etc.), by method (observation,
interview, document), by researcher (investigator A., B., etc.) and by theory
(Miles & Huberman, 1994, p. 267). I asked questions and observed
behaviors in different settings and within different groupings as well as in the
individual interviews. In this way, I gathered data on multiple levels and at
42


multiple times to triangulate the findings. As the study progressed, I worked
with the participants to construct operational definitions of the words,
attitudes, and behaviors that explain what the data actually represent to
those involved in the study (Krathwohl, 1998; Lancy, 1993). Ensuring the
validity of data and findings over time and across situations and individuals
also ensures reliability.
The Researcher: Perspective and Roles
In a qualitative approach, the researcher is the primary data collection
and analysis instrument, and all data are mediated through this instrument.
A qualitative case study is inherently interpretive, and the perspective of the
interpreter must be explicitly stated in the study by identifying personal
experiences and interests that contribute to the researchers perspective
and biases (Cresswell, 1994; Merriam, 1988). Stake (1995) recognizes that
the researcher interacts with the phenomena. Rather than attempt to
eliminate that interaction, it is best to give the reader a good look at the
researcher (p. 95) by clearly stating the researcher perspective and
adhering to an explicit research routine that informs the reader about all of
the elements that contribute to the descriptions and interpretations provided.
Researcher Perspective
I am a life-long resident of the City and, now, County of Broomfield. I
am interested in the well being of the community and participate in the
43


residential, consumer, educational, and political environment. My son
graduated from and my daughter attends the local high school, my alma
mater. My parents still live in the house in which I was raised, and the
offices of Health and Human Services are less than a mile from that house.
My interests in individual and systems change have evolved over
years of experience in the private, non-profit, and public sectors.
Participating in a variety of organizational cultures and fulfilling the roles of
leader, manager, supervisor, and staff member have contributed to my
beliefs about change. I bring to this study experience in implementing both
personal and organizational change. My experience has sensitized me to
the behaviors of individuals in organizational settings, with particular
awareness of the behavior of organizational leaders as they attempt to
implement and sustain change.
I am interested in the concept of integrated services and the potential
it has for improving outcomes for families and children. My belief is that
services integration is a good idea facing barriers and constraints to
implementation in the existing services systems. Though my background
does not include practice in the public health and human services fields, my
experience contributes to my beliefs that systems change is complicated
and problematical. The systems of health and human services are well
established and the methods of operating in those systems have become
44


entrenched over time. I believe that progress toward services integration in
any county health and human services system would be very difficult.
When the Broomfield county initiative was proposed for the
November 1998 ballot, I had just begun my first semester of the doctoral
program at the University of Colorado at Denver. My chosen field of study
was Educational Leadership and Innovation, Integrated Services for
Families and Children. Though my dissertation was on a distant horizon,
and the initiative had yet to gain favor in the November election, I realized
that the possible changes in Broomfield would supply an interesting and
unique opportunity for study. In particular, the feasibility study prepared to
support the ballot initiative included an extensive explanation of an
integrated services model proposed for the new Broomfield County. The
feasibility study states that Broomfield will be a champion of change and
innovate local government. This appealed to me as an opportunity to study
systemic change as it happens, and an opportunity to observe the
implementation of integrated services in a county system.
I began this study with this perspective: though the creation of a new
health and human services organization is an excellent opportunity to
implement systemic change, and the change effort has been undertaken
with enthusiasm and support, the endeavor is a challenge. The individuals
45


and the systems will act and react in ways that they find both unanticipated
and surprising.
Throughout this study, I have taken steps to maintain my stance as a
researcher. However, my experiences, beliefs, and perspective may have
influenced my observations and interpretations.
Researcher Roles
Because I was the primary data collection instrument, it was
important for me to note the times and places where my experiences and
biases may have influenced my research activity. As I took notes,
participated as an observer, and conducted interviews, I paid special
attention to my choice of words, my changing roles, the level of my
participation, and the possible influences my participation had on the
particular activity.
My role as researcher was as participant observer as I described and
attempted to understand the events, discussions, and activities in the setting
as the case developed (Krathwohl, 1998; Spradley, 1980). I am a
participant in the setting as a contractor to the Department of Health and
Human Services as a community advisory group facilitator and the
leadership development and team-building process facilitator. I was a
contractor to the department for six months prior to beginning the research
and throughout the study time frame. Negotiating multiple roles added to
46


the complexity of conducting the research. The identification and
explanation of my different roles are included as data in this study.
My role as participant observer gave me a unique research
perspective. Though I provided frequent reminders to myself and to the
participants of my researcher status, relationships inevitably developed with
many of the participants. My status with some quite naturally moved from
outsider to insider. Consequently, the descriptions of situations and events
will be different from those of an outside researcher, with interpretations rich
with details of close proximity and insider information.
My participation in the leadership development and team-building
process may have resulted in actions, decisions, and discussions by the
other participants that may not have otherwise occurred. Therefore, my
participation is included as data. The qualitative approach allows for the
participant observer role by bracketing the contribution of the researcher
through clear and complete descriptions of the researcher perspective and
participation (Stake, 1995). The qualitative tradition also includes a caution
against studying phenomena in ones own backyard and in which one
clearly has a vested interest (Cresswell, 1998). Though Broomfield is in my
backyard, my participation in this case is not vested in particular outcomes
or interests related to integrated services or systemic change; and my
interests are not vested in the Health and Human Services Department nor
47


the City and County of Broomfield organization. My participation is
bracketed as a participant observer and contractor. I am not an employee of
the City and County of Broomfield, and my contract does not include
services related to decision items or program areas.
Approval, Confidentiality, and Informed Consent
This study has been approved by the University of Colorado at
Denver Human Subject Research Committee and the Director of the City
and County of Broomfield Department of Health and Human Services in
consultation with the Assistant City Manager. The key participants were
invited to participate voluntarily in the interviews and granted their formal,
informed consent. (Copies of the UCD Human Subjects Approval is
included as Appendix E.)
Every effort has been made to ensure participant confidentiality.
Because the study is sanctioned by the City and County of Broomfield and
the director of the department of health and human services, some
information may be shared with the director and the city and county. The
shared information has been coded to protect the sources of the information,
yet due to the small number of participants, their anonymity is not
guaranteed. Each participant has been provided with a description of the
study along with explanations of my request for their participation and the
requirements of their participation. Each participant has been given an
48


opportunity to ask questions or express concerns related to the study and
has been invited to read the completed study.
The Case Study Report
The data collection methods described here yielded a magnitude of
data. The analysis of the data included the task of carefully considering the
themes that emerged to address the research questions, and giving priority
to those themes over others. The case study report is intended to be a
careful, rich, thick description of those themes (Cresswell, 1998). The report
that follows is a presentation of the case based on the data relevant to the
phenomena of interest. Whatever is to be included in a descriptive account
needs to be assessed for its relevance and contribution to the story being
developed (Wolcott, 1994, p. 57). This is a descriptive case study, and the
reader should give careful consideration to the descriptions that are
provided here, as well as consider potential descriptions not presented here.
Emphasis itself is a critical aspect of descriptive work. One draws attention
to some things while slighting others (Wolcott, 1994, p. 56).
With an emphasis on description, I use the participants words as
often as possible to tell the story about the innovation, and to provide the
evidence of their efforts to develop a new approach to public health and
human services. My interpretation is woven together with theirs, and I use
their words and my observations to present the following report. Together,
49


the participants and my perspectives comprise the description of the
phenomena studied. Chapter IV presents the data, organized in accordance
with the themes that emerged as relevant to the questions that were posed.
Chapter V presents a discussion of the implications of the results, along with
the limitations of the study and issues for further consideration.
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Chapter IV
Results
The purpose of this case study is to provide a description of the
implementation of an innovation. The research questions that guided this
study are as follows: How do the individuals and the systems respond to the
proposed innovation? What evidence emerges that reveals their efforts to
develop a new approach to providing health and human services? The
results of this study are presented through three descriptions: the context
for the study, the vision for integrated services, and the process of
implementing the vision.
Context
The context of the innovation and this study includes the place, the
people, the time, and the task. This information is presented as an
introduction to the community, the setting, the participants, the innovation,
and the phenomena of interest.
The Place
The city of Broomfield, Colorado, became the new City and County of
Broomfield on November 15, 2001, the 64th county in the state of Colorado.
Broomfield is located along the front range of the Rocky Mountains in the
central part of the state. It encompasses about 33 square miles and, based
51


on geography, is the smallest county in Colorado. The last time a new
county was formed in Colorado was in 1902 when Adams County and the
City and County of Denver were created out of portions of Arapahoe County.
The City and County of Denver is the only other city and county entity in
Colorado (Holeman, 1998). Broomfields new city and county organization
is one entity required to perform the functions of both city and county
governments.
On November 15, 2001, the population of the new Broomfield city
and county was 41,865, making it the 15th largest county in the state based
on population (By the Numbers, 2001). Broomfield is considered a suburb
in the Denver metropolitan area and is situated equidistant from Denver and
Boulder along the U.S. Highway 36 corridor. Before becoming its own city
and county, Broomfield was situated within the boundaries of four different
counties: Adams, Boulder, Jefferson, and Weld. The population of
Broomfield is projected to grow to about 75,000 when the county is fully built
out, which is projected to happen by the year 2023. According to the 2000
Census, the race and ethnic distribution of the population is as follows:
88.6% white, 0.9% black/African American, 0.6% American Indian, 4.2%
Asian/Pacific Islander, 9.1% Hispanic/Latino, and 5.7% other. Broomfield
has been described as an affluent, educated and prosperous community
(Holeman, 1998, p. 9).
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Prior to becoming a city and county government, Broomfield citizens
had expressed concerns about the quality and availability of accessible,
equitable, and efficient government services provided by the four different
counties. They were dissatisfied with what was perceived as an imbalance
in the level of property taxes and return in government services. They also
recognized inequities across the city because services were provided by
four distinct and different jurisdictions. It was perceived that becoming a city
and county government would provide local control over the revenues and
expenses associated with required government services and would greatly
improve the efficiency of service delivery and reduce the complexity of multi-
governmental service providers (Holeman, 1998, p. 14). A key focus for
becoming a city and county government was the more efficient and cost-
effective streamlining of service delivery across all government systems.
This study focuses on the newly created Department of Health and
Human Services. The department is organized with six divisions:
Administration; Operations; Elderly, Disabled, and Medical Services;
Families and Childrens Services; Self-Sufficiency and Employment
Services; and Public Health. The Administration and Operations divisions
do not provide direct services or have program responsibility. Rather, the
Administration Division is the executive arm of the department and consists
of the director and four support staff; the Operations Division provides the
53


budget, facilities, and information systems support for the entire department.
The other four divisions provide direct services and have program
responsibilities in areas described by their division titles. The department
reports directly to the city managers office through the department director
and is one of ten departments in the city and county organization.
The People
The key informants for this study are the director and five managers
of the new Health and Human Services Department. The six key informants
were the primary sources for data during the course of the study. The
director came to Broomfield in August of 1999 in a contractual arrangement
with the State Department of Human Services where she remains a state
employee, on loan to Broomfield until the end of 2002. Three of the
managers came to Broomfield in July of 2001, one arrived in August, and
the last of the managers was hired in November just one week prior to the
new countys opening day. Also included as participants are certain staff
members who were selected because they were the only employees of the
department when the study began, and they participated in many of the
meetings and initial activities related to the development of the department.
Other staff in the department knew of the study and may have attended one
or more meetings or participated in one or more conversations where data
were collected.
54


The director and the managers are three males and three females.
The director is female. They range in age from 29 to 59, with one manager
at 29 years of age, two in their early 40s, and three in their mid to late 50s.
They have a myriad of experience and education. Five of the six have some
form of government experience, and all of those five have some kind of
county government experience. Only two of the six have any private
industry experience. Neither the director nor the managers are residents of
Broomfield. A more precise summary of the key informants education and
experience is attached as Appendix F.
The Time
The study occurred during the time period from August 1, 2001,
through April 1, 2002. During this time, the Health and Human Services
Department was designed, organized, staffed, equipped, and opened.
Transfers of cases from former county providers and new client applications
began on November 15, 2001. No health or human services were provided
prior to that date. Because of the payment cycles for certain types of human
services, clients who had previously received general or cash assistance
from one of the other counties were actually transferred as of December 1
as their cases had been processed and paid for through November 30 by
the prior provider. A few cases were not transferred from the other counties
55


at all if it was determined that a change in services or caseworker might be
detrimental or harmful to the client.
The original plan for public health called for the existing public health
agencies to continue to provide services to Broomfield residents through
contract arrangements with the new county. In August 2001, unresolved
disagreements between the existing providers and Broomfield resulted in
changing the plan so that public health services would be provided directly
by the new county department. Broomfield contracted with the existing
providers for temporary services for Broomfield citizens until public health
professionals were hired and programs developed. Environmental health
services were available on November 15, and the remaining Public Health
services became available in a staggered fashion as the programs were
developed and people hired.
The Task
The innovation that is the subject of this study is two-fold: creating a
new health and human services department, and implementing a new
approach to health and human services. The creation of a new county
requires the development of county-level services to replace government
services provided by the previous four counties. State statute requires that
the county provide public health and human services to county citizens
either by contract with provider agencies or through direct service provision.
56


Local county-level services of all types were new to the city organization, the
existing employees, the community, and the citizens.
By creating a new government, Broomfield believed it would have the
opportunity to design a human services system with a focus on outcomes
and a comprehensive approach to serving at-risk individuals. The intent
was to design an innovative and more integrated system. The feasibility
study for the new county indicated that Broomfield would have the
opportunity to reinvent all government services. The intent was to either
privatize or outsource many of the programs and services that would
comprise health and human services (Holeman, 1998, p. viii). The plan was
changed shortly after the director came to Broomfield such that all human
services would be included within the new county department. Providing the
services using an integrated model of service delivery was part of the initial
plan and remains a key concept for services in Broomfield.
An integrated services system is considered different from a
traditional or historical system for services. Traditional services have been
described as targeting specific populations or specific problems and as
fragmented and unconnected. Individuals and families navigate a complex
system, filling out multiple forms, meeting with numerous caseworkers,
providing the same information over and over. Integrated services are
described as connected and coordinated, crossing boundaries of
57


populations or programs for the benefit of the recipient. The workers
navigate the complex system so that clients meet with fewer caseworkers
and provide their information once. Funding streams are not barriers to
services, and solutions are based on clients needs not available services.
In an integrated system for services, the client is viewed in the context of the
family, the neighborhood, and the community.
The Vision
Throughout the study period, there were opportunities to observe the
participants efforts to create a new department for health and human
services and a new approach to providing services. The vision for the new
department was developed first in the feasibility study for the new county.
The study stated that based on the intent to streamline and reinvent
government services, health and human services would be integrated and
innovative with an emphasis on better outcomes. The new approach was
further developed by the director, supported by the policy makers, and
conveyed to staff members and the community over time. In October, the
participants created vision and mission statements as shown in Appendix G.
They talked about creating an integrated services system and doing
business differently. At every meeting where the department was
introduced or described, the participants took the opportunity to highlight the
concept of integrating services.
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The director of the department used four cornerstone concepts of
independence, preservation and prevention, community wellness, and
restoration to describe the foundation and philosophy for services and
programs. The central concept for the cornerstones was integration of
services (see Appendix H). In July 2001, the director brought the
department employees together to talk about her vision for integrated
services in Broomfield. She articulated her vision to the attendees as
follows:
So where did this come from, this idea of integrated services? And
why did Broomfield decide to do this? I remember sitting in the state
offices and having conversations about how you could do integrated
systems. These conversations came out of frustration at seeing
repeated instances where client plans were in opposition to each
other. I remember there was one case where there was a family on
child welfare, a mom who had twins. One of the twins needed
serious medical care and was in the hospital. The doctor required
that she attend a Medicaid staffing for the sick child. She was also
required to attend an orientation for her TANF benefits. Both of these
required meetings were scheduled at the same time. The mother
chose to attend the TANF orientation so that she wouldnt lose her
TANF grant. When she missed the Medicaid staffing, the doctor
turned her in to Child Protective Services for neglect of the sick child.
These kinds of situations happen all the time. There are so many
barriers in the systems that keep us from doing it differently. When
we were sitting in the state offices, we said that we would actually be
able to do integrated services when all services fall under a single
fiscal agent. When the ballot initiative for creating Broomfield County
passed, we saw it as the opportunity to really get integration done.
Along with making sure that Broomfield residents have access to
county services locally, part of the focus for creating the new county
was to reinvent government and do things differently. Broomfield
59


City Council has adopted the ideal of integrating services with the
intent of doing it better. When I heard one council member use the
phrase turning the stovepipes on their side in a public meeting, I felt
like they were really getting itthe idea that it was different than what
is being done everywhere else, and that it just makes sense. They
are clear that they want to see local services integrated across
populations, and they expect that we will be creative in making sure
we get it done. (Transcript of meeting, July 18, 2001)
The stovepipes refer to the traditional funding, programs, and
services that flow from the funding source to the clients in rigid, categorical
streams. Turning the stovepipes on their side is one way of describing
integrating services across boundaries of funding streams, populations, and
program requirements. The participants struggled with defining integrated
services as they worked to operationalize the vision. A definition of the term
and a shared understanding of its meaning evolved during the study period.
A Work in Progress
The managers recognized that the concept of integration was
something that would evolve as the department grew and services were
established. In interviews near the end of the study, one participant said, I
think its going to be a work in progress. I think thats inevitable. Another
added, I dont know if youre ever done, if we ever can say, ok put a cap on
it, were done. Were integrated. The community would change, the laws
could change, and the organization would have to be responsive to those
changes. Very little information existed about the numbers and types of
60


clients the department would see, and the department wouldnt know the
clients or understand their needs until they began to serve them.
The participants said they wanted to be a learning organization that
responded to new information as it became available and made adjustments
as were necessary. They also expressed concern they would open with
mandated services and systems that allowed them to function, but then
changing those services and systems to be integrated would become more
difficult as each day passed. Just as the department was ready to open,
one manager asked, Will we still be committed once things are operating?
Will we want to change then? They agreed integration was a process, and
the services and the organization would have to evolve and change.
In January, the managers developed a working definition of
integrated services and conveyed that definition to staff members at a staff
meeting: Integrated services is a process that is client-focused, outcomes-
based, innovative and risk taking (willing to do something different to support
individuals and families) in service to the community. However, in March
the director remained concerned there wasnt agreement about what
integration is and what is expected of the staff members. She addressed
the managers: The fact that we havent answered questions for ourselves
is indication of why staff is so confused. Many of those who had worked in
other counties said the county they came from was doing integrated
61


services because it was the way the other county described their system.
Because it wasnt specified in Broomfield, they couldnt understand how it
was going to be different in Broomfield. The language being used meant
different things to different people.
As the study came to a close, the participants were still talking about
what integrated services means and how the innovation will be put into
practice in Broomfield. Certain concepts emerged as threads from which
they were weaving a shared understanding of the innovation. In their words,
these concepts were co-location, working outside of HHS, prevention, and
its about the clients.
Co-location
The concept of co-location emerged as key to integrated services.
Co-location is placing different functions together either in physical space or
organizational structure. During the study period, there were several
examples of how having programs, services, and people located in close
proximity were important aspects of integrating services. Having public
health here is huge, a participant explained. Combining the public health
functions with human services functions in a combined health and human
services department was very different from other county departments.
Public health sees the same clients as human services. When they are
62


separate, they dont easily work together to meet all of the clients needs,
and some of those needs go unidentified or unmet.
Public health has a prevention focus while human services has a
more traditional treatment focus. These two functions together provide a
broader spectrum of programming and services options along the
prevention-early intervention-treatment continuum. In Broomfield, the TANF
(Temporary Assistance for Needy Families) human services program and
WIC (Women, Infant and Children) public health programs see the same
clients and work together to provide education and identification of needs.
The child welfare workers and public health nurses participate in joint
staffings to identify childrens health issues as well as abuse or neglect.
Another example of co-location is the combination of TANF, child
support enforcement, and employment services in the Work Force Center
within one division. In other counties, each of these programs is large
enough to stand alone and are consequently separate from each other with
different managers who may or may not be willing to work closely with each
other. A client in TANF who needs food stamps or general assistance may
also need child support collected from an absent parent and help finding a
job to eliminate the need for TANF. By locating TANF, child support
services, and the Work Force Center under one division umbrella, the client
and various staff members work together during one visit to accomplish
63


what might otherwise require three visits with three different service
providers. By locating the TANF programs in the same building with the
child welfare programs, the caseworkers develop family service plans that
(a) do not have conflicting program requirements and (b) address the needs
of the clients in the context of their families. One of the division managers
said working together made sense: The TANF caseworker cant tell the
mom that she has to work at the same time that the child welfare
caseworker tells her that her child is in trouble and needs her at home.
Another example of location under a single division umbrella, though
not physically located in the same building, is the inclusion of the Senior
Center within the Elderly, Disabled, and Medical Services division. The
Senior Center has been part of the city organization and serving Broomfield
seniors for more than a decade. When the Health and Human Services
Department was formed, the Senior Center organization was included in the
new department. The Senior Center serves many of the same people who
qualify for and receive services for the elderly. These include Old Age
Pension, Area Agency on Aging services, and Veterans services. Placing
the Senior Center together with other health and human services programs
was designed to increase the potential to streamline programs, improve
communication, and eliminate duplication.
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However, co-location is not integration. Clients are still referred from
child welfare to public health, from the eligibility specialist in TANF to the
childcare worker in child welfare. There are benefits for the clients by
making connections between and within divisions, but integration means
something more. In a March 2002 interview, the director explained: Co-
location is a start. Using each others services is a start. But to plan
integrated programs, I think thats the piece we still have to do. Integration
has to be focused on more than we just sit next to each other.
As space becomes an issue and the department outgrows its current
facilities, the concept of co-location as key to integration will be tested. The
director said that she will fight to the finish to keep us all here together as a
symbol of what were trying to do.
Working Outside of HHS
Another concept that emerged as key to integration is the concept of
working with providers and agencies outside of the Health and Human
Services Department. In an August 2001 interview, one participant
described the concept: Its not just human services alone. Its us working
with mental health, with substance abuse providers, with the courts, with
probation. In addition, it is working with other city and county departments
that serve the community or support the city and county. The police have a
strong presence in the community and within the city and county
65


organization, and enforcement and public safety are high priorities. Finding
ways to combine those priorities with and dedicate resources to the
cornerstones of independence, prevention and preservation, restoration,
and community wellness are a challenge. Difficulty arises when the other
providers have already been working in the community either as part of the
existing city organization in the case of the police, recreation, public works,
and the senior center or under arrangements with the four former counties in
the case of mental health, substance abuse, and the courts.
In August and September of 2001, many of those providers didnt
know what the health and human services department intended and how
they could participate. While riding along with a police officer in August, the
officer told one manager that they dont have a clue as to what you guys
do. At the same time, another city employee wondered:
We keep hearing about the integration of services that you guys are
doing. How can you integrate if you dont talk to us? We see when
kids are in trouble. We could work with employment services
because we have needs for seasonal labor. We would hate to be left
out of improving services in the community. (Transcript of
conversation, August 27, 2001)
In September, mental health workers asked the managers, How do we use
these dollars to get the services and staff the functions for what Broomfield
needs? The health and human services managers had to educate other
66


providers about what was intended and then work with those providers to
identify how they could create integrated services.
In March 2002, the process of working outside of the department was
still evolving. One manager commented, We do it periodically across other
departments but nothing on a regular basis. She cited an example of the
police departments training manual with little mention, if any, of how you
interact with social services. And theyre willing to revise it, were working
with them on that. But, she said that mental health is still saying heres
what we have rather than what is it you need? Another manager said that
it is working with the courts and the senior center, and its a very, very small
piece of community service but thats a good place to start.
Prevention
Another concept that emerged as important to integrated services in
Broomfield is prevention. Prevention is avoiding negative outcomes and
events for individuals and families. The whole community and the whole
family is the focus when you integrate public health and human services.
One of the participants explained this idea well.
In unhealthy communities, there is more crime, you have to deal with
teen pregnancy and the poverty and illness that are often the result,
and homelessness increases. Delivery and prevention can work
together. There are grants for community groups to do prevention in
child abuse, and to focus on the prevention aspects of other issues.
The WIC program is eligibility driven but it also helps to prevent other
negative outcomes for mothers and their children, so it is both
67


prevention and treatment. (Transcript of conversation, November 15,
2001)
However it is difficult to quantify the effects of prevention and to find
funding for prevention services. If the negative outcome doesnt occur, to
what do you credit that success? The director explained:
Do you track it to the prevention that you did in child welfare? Do you
track it back to enlightened law enforcement? Do you track it back to
new laws? Do you track it back to a communitys willingness to do
more community based policing rather than punitive imprisonment?
You cant track it back to anything. (Transcript of interview, March
19, 2002)
With the opening of the new county and the accessibility, availability,
and local control over services to citizens, there is an increased awareness
of the problems that are addressed through health and human services.
Several high-profile child welfare cases were the first that the department
had to deal with, and the local newspapers carried the cases on the front
pages and in special sections. As those cases became public, actual
caseloads and numbers of clients were also being reported to city and
county officials. One participant explained that the officials want those
problems fixed immediately and be sure they dont reoccur. The only way
to do that is through prevention, so there has been a strong commitment to
funding prevention services. However, as money gets tight in tough
economic times, this person added, it will be interesting to see if they are
willing to pay for prevention because you cant do prevention for free.
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"Its About the Clients"
One of the concepts often discussed as a key foundation for
integrated services is that integration produces better outcomes for the
clients. In October, one participant described it: We need to look at the
point of contact to look at delivery of services. The services are about the
clients. In March, the same participant explained further:
Its not an internal thing. Its an external thing. It is the impact we
have on the people we serve. Were charged with trying to define
integration, but the funny thing about it is were not the beneficiaries
of integration. Somebody else is. The clients are. The public is.
The struggle faced by services systems is meeting the needs of their
consumers who, most of the time, would rather not be consumers if they had
the choice. They dont line up to receive public assistance if there are other,
better options, and being publicly vocal about what they need is something
most clients do not do. Finding a way for clients to have a voice in the
creation and development of services was key to integrating those services
on their behalf.
The managers and staff members created different work groups and
task groups so that the workers who were dealing with clients could
represent their clients needs to others in the development of services and
programs. One of the groups they formed was a TANF support group. The
TANF program manager explained, Rather than be presumptuous about
69


what TANF participants want and what they need, we just decided to ask
them. The TANF recipients direct what they want the group to look like and
what kinds of services they need and will ask for.
Another way of encouraging client involvement is through the public
health programs. The public health manager described the possibility:
Public health can do outreach to the community and the needy in a good
way, through immunizations and nutrition which have a positive community
perception. If TANF were to do outreach, it would be seen as advertising for
clients to come in for public assistance. Thats not a good way. The
participants agreed it is important to have a client focus, yet difficult to get
clients to the table. One described it as finding a way to have meaningful
roles for the clients in developing services. Not just as a participant, but as
a planner, and have them involved in the department. Another, in a
community meeting, summed: I came here to do what others are only
talking about. And the biggest challenge to innovation in service delivery is
getting the clients involved.
Implementing the Vision
Defining the innovation over time, the participants were
simultaneously implementing the vision in various ways. The task was to
create a new department and to implement a new approach to services.
Certain themes related to the task emerged as important. The iterative
70


coding and analysis of the transcripts of interviews, meetings, and
conversations revealed these themes as central to the participants efforts to
create the new department and to develop an integrated services approach.
The participants efforts throughout the course of the study revolved around
the themes of the community, the city organization, funding, information
technology, the new department, work groups, and the generalist approach.
The Community
The participants said that the services were about the clients. They
also said that the clients are part of the community. One said that the idea
for integrated services is to make it community driven, making sure that
what we provide meets the needs of the community. Another explained
further that, with limited resources, it is important to use those resources to
address priorities: Before we build any big programs and before we spend
money, we need to look at the community and see whats needed. The
department personnel didnt have an understanding about what was needed
in the community, and the community didnt have an understanding about
ways to meet their needs, so there was some confusion early on about what
the goals should be for health and human services in the Broomfield
community.
The perception in the community was that many of the problems dont
exist in the community. One manager was told by different funding sources
71


Broomfield was too well off and you dont have enough troubled kids here
to get funding. Providing services in the community forced recognition
those problems did exist. Instead of the pockets of at-risk individuals, in
need of traditional county services described in the feasibility study
(Holeman, 1998, p. 9), much more widespread need became apparent as
services became accessible in a community where services were previously
not available. During the planning phase, projections of caseloads for
Broomfield were hard if not impossible to come by. The Broomfield data
was aggregated in each of the prior four counties caseloads. The feasibility
study did not project numbers of cases or clients but did project that the total
annual cost for health and human services in Broomfield would be around
$2.7 million, which included the outsourcing of public health and other
services to independent contract agencies (Holeman, 1998). In actuality,
the approved health and human services budget for 2002 has an annual
expenditure amount of approximately $7.6 million including all allocations,
appropriations, and county-only dollars. This amount, considerably different
from what was projected, is based on actual case loads and services
provided in the community.
Citizens in Broomfield are used to being able to communicate with
city officials and policy makers. From the time the initiative was passed and
the director came to Broomfield, citizens have contacted the director and
72


spoken with her candidly. They want to be able to let her know what they
see and want in their community. In one meeting, she explained, Most
directors never talk to the community. Here, there are a lot of people in and
out of the department. They arent services recipients, but they are curious
about whats happening and whats available.
Broomfield has a high level of community involvement. This is
evident in the creation of the new county, which was a grassroots effort
started and carried throughout the state by community members. In
addition, there are 14 advisory committees providing input and
recommendations to city council on issues ranging from open space,
culture, and library to land use, capital improvements, and the master plan.
The community is used to having a voice in matters concerning the city and
county, and the advisory committees provide citizens the venue for their
voice.
The city managers office and the city council want the department of
health and human services to interact with the community on issues of
services and program development in the same way as other departments
have interacted with citizens to receive input and guidance. To that end,
they created the Human Services Advisory Committee and the Public Health
Advisory Committee. Citizens were appointed to the committees by city
council. A total of 28 residents serve on these committees along with three
73


city council liaisons and different staff members who attend committee
meetings to provide information and background on different issues.
The participants agreed the community should be involved in the
development of programs and services. One described it as crucial that we
need to really have a meaningful way for the community to participate, to
really engage the community in the process. However, there were
problems with the advisory committees. First, creating two advisory
committeesone for health and one for human servicesis functionally at
odds with the goal of services integration. In order to address programming
concerns that cross boundaries of health and human services or prevention
and treatment, both committees need to be educated and involved. This
requires duplication and overlap, and some of the information and dialog is
lost between the two committees meetings.
Second, through the process of obtaining committee input on
services for the developmentally disabled, it was perceived that some of the
committee members and some of the staff members were advocating for
personal and policy agendas. The process that developed for addressing
this topic established a precedent that limited free and open discussion of all
difficult or controversial topics. The human services committee and the staff
professionals who worked with the committee became stuck in formal
committee processes and opposing views, and the department began to
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view the committee as dysfunctional and useless. Some topics were
eliminated from future agendas either to avoid the process or to meet
decision deadlines.
At the close of the study, the city managers office and the health and
human services department were looking for ways to restructure the two
committees. They wanted to maintain community involvement but eliminate
the problems with the current committee structure. It is unclear how
community involvement and the advisory committees for health and human
services will evolve.
The City Organization
The city of Broomfield was incorporated in 1961. Systems for
operating and supporting a municipal government organization were already
well established, and the new county functions would not begin until
November 15, 2001. While the participants were building a new
department, they had to work with existing departments and learn about the
existing organization. One of the managers said, Its not like were setting
up an entire new system. Weve adopted a lot of the city ways of doing
business. Existing city structures and operations continued to have a
strong influence on the development of new county structures and
operations. The county commissioners were still called "city council, and
the city and county offices were still city hall.
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Being physically separate from the support services of the city and
county added to the difficulty of working with and learning the culture of the
existing organization and educating the existing organization about the new
functions. This separation created some difficulty early in the process, as
one participant explained: By being physically separate, there is a sense of
us and them that is hard to overcome. Different parts of the organization
such as the police force and the recreation departmentwere already
dealing with the health and human services population through other county
agencies before the new county agency was formed. They had an
established way of operating with the former providers, and they expected to
continue those operations with the new Broomfield agency. In addition, the
methods used for staffing, information technology, budget, and
communications worked for the existing city and were expected to work for
the new county. As the participants were trying to hire people, order
supplies, and develop policies and procedures, they expressed concern
about being separate from the rest of the organization and being told this is
the way we do it. One commented that it is an impediment to developing
the new department and the integrated services model if we need to be
nimble and agile about getting this going.
Some of the participants also described an emerging understanding
that the city and county has an inherent focus on integration in a much
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bigger way than in just health and human services. One described surprise
that at the city level I do not see the silos, you know, those little silos of
power, that Ive seen everywhere else Ive been. All the department heads
just seem to be open to anything that brings better service. They dont have
a turf staked out. Another expressed:
The singular theme is better government, better service delivery and
how we do that together as a bigger organization. Whether the city
calls it integration or not, it sure as hell looks like integration to me.
They all seem to have the same kind of words coming out of their
mouths. So I dont know if it is a change or just maybe a recognition
that it really has been here and its really not unique to human
services. Its sort of the city, and now the city and county, culture and
philosophy on how to deliver services, I dont know if I would define it
as change, more of just a recognition that its here, and its bigger
than us. (Transcript of interview, March 5, 2002)
Two of the participants, however, were skeptical about the actual
motivation for integration with other city and county departments. One of the
participants described it as a method to achieve a happiness index that
was the measure of success in Broomfield.
The culture of integration in Broomfield is around customer service
and the happiness index. If a citizen is unhappy, they need to be
made happy and that is the citys job. But you cant fix people, you
cant always make them happy, so having the community involved by
letting us know how unhappy they are or having city council and other
departments involved in giving them what they want isnt the way that
health and human services operates. (Transcript of conversation,
May 24, 2002)
There is a difference between working with people who would prefer not to
receive services if they had a choice and working with people who demand
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services for their tax dollars. Making health and human services clients
happy isnt always possible.
In addition, because the city organization believes it is already
working across department lines to provide better customer service, having
the county health and human services organization talk about doing
business differently creates some resentment. One of the managers
commented, The city people think theyve been doing just fine without the
county people and therefore they dont want us to take any lead. Another
participant said:
We are finding that it is harder to do when people in the city find out
how it will touch them. We have to ask the question is the vision to
change? and if so then it has to be ok for us to proceed and we need
organizational support to do that.
Fundamentally, a city is different from a county. A main difference is
in how the city and the county are each held accountable. One of the
participants summarized the difference as follows: A city organization is
accountable to the citizens. A county organization is accountable to the
funding source, the feds, the state, the clients. There are much bigger
responsibilities and consequences for non-compliance than being
responsible to voting citizens. A county serves the citizens, just as a city
does, and is concerned about meeting citizens needs, just as a city is. But,
accountability and consequences for county governments are at a different
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level than for city governments. These two systems are combined in
Broomfield and a shared culture will emerge as the new organization is
established. The participants recognized a reciprocal influence of the city
culture on the county function and the county function on the city culture. At
the close of this study evidence showed that a shared understanding of what
exists at the city level and what needs to be done to accommodate county
functions is still emerging and will be in process for some time.
Funding
The systems that allocate funds for health and human services are
complex and confusing. Federal money goes to the state for distributing
block grants to counties. The state allocates and appropriates funds based
on historical spending, the numbers of clients served, the types of services
provided, and the amount of staff time spent with each client or program.
Each county is required to supplement the block grants and state allocations
for services and programs in their community. City organizations, private
foundations, non-profits, and corporations grant money to organizations that
serve communities. These funds are all distributed with specific restrictions
and accountability requirements. Tracking and reporting to the funding
source is the only way to receive reimbursements for services already
provided or funding for services in the future. Even the block grants are
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handed out with inclusions, exclusions, and significant penalties for using
the funds in any other manner.
Though Broomfield is developing an integrated system for services,
the funding system is not integrated, and the restrictions and requirements
in the funding systems were not waived for Broomfield. There were six
components of the overall budget, including four direct service areasfamily
and childrens services; self-sufficiency and employment services; elderly,
disabled, and medical services; and public healthplus operations and
administration. Several participants said services cant be integrated if the
money is not integrated. One of the managers expanded:
The block grant gets you part of the way there. Money management
is easier if you stay between the program lines, and in other counties
the staff has to worry about being between the lines. Here, we want
the staff to think about the clients needs so the client doesnt end up
not being served because of a money issue. Let the managers worry
about the money lines. Blending funding across the lines allows you
to leverage the money you get to provide more services, because any
one pot of money is not enough to provide all the services that are
needed. (Transcript of conversation, September 26, 2001)
One manager also gave this message in his staff meeting: Who cares
about the money? The managers will worry about the money so dont let
that get in the way of service delivery. We shouldnt let money drive the
bus. The intent is to let the money operate behind the scenes and let the
clients needs drive the bus.
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The operations manager and the director created the original
department budget, and the operations manager had overall budget
responsibility. As the budget was presented, revised, and refined, each of
the managers began to focus on their division budget. They agreed that
the budget and funding streams were a critical element of integration, and
they said they would work together to integrate funding streams. At one
managers meeting in March 2002, they talked about pitching in some of
their money for programs and services, each wanting to know how their
clients would be impacted by the program or service before they pony up.
The program area managers took ownership of their budget and didnt want
budget decisions to be made solely by the operations manager. One
participant described the concern: Other counties have been in a position
where they maintain the stovepipe funding and programs because thats
how they developed. Broomfield is faced with the same stovepipe funding
as other counties, and is developing individual budget responsibility for
expenditures and revenues that segregate funds based on department
divisions.
Neither the state nor Broomfield allocated adequate money for the
planning and start-up costs for the new county. Broomfield faced allocation
issues stemming from not having any historical spending and baseline data
about how many clients to expect in each program area. There was not any
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previous discussion about the fact Broomfield was a start-up and needed
money allocations for planning, case transfers, computers, space, and staff.
The other counties were continuing to provide services to the clients who
would be Broomfields, so the state allocations remained with the existing
service providers until November 15, 2001. Neither Broomfield nor the state
allocated money to plan for services to be provided by the new county.
Once Broomfield was up and running, it was faced with the same funding
restrictions that all counties face. One of the participants articulated the
problem, There needs to be a willingness to have funds set aside to support
development of new activities even though youre not going to see that
youre getting your moneys worth until its done and being able to be used.
Most funding sources do not allocate money for prevention services,
so a focus on prevention presents a problem of reimbursement. If it cant be
countedclients, services, timeit cant be reimbursed. Negative
outcomes that dont occur cant be counted, and positive outcomes often
cant be tracked back to prevention programs or services. Funding for
prevention is often county-only funding, so the county must understand and
commit to preventing negative outcomes that could be more expensive in
the long term. One participant pointed out, Broomfield certainly has agreed
with the concept of prevention, but when push comes to shove when money
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gets tight, whether or not there will be interest in maintaining prevention I
think remains to be seen.
Information Technology
Funding and information systems are closely linked. Funding is
dependent upon data. Each funding stream has requirements about how it
receives that data. When it comes to tracking and reporting, the funding
hangs in the balance. The burden of proof is on the county when it comes
to requesting reimbursements for services already provided. In an interview
in March 2002, the director explained, The county has to pay the tab for any
services that are outside of the vision or the scope the state specifies. The
tracking and reporting is required to minimize county-only dollars.
Some programs fund the data systems that support the program, and
the systems are restricted for use with only that program. In an interview in
March 2002, a participant described, There are some counties where they
have more computers than they have staff because the computers are
specific to a program. There are also separate tracking systemsCWEST,
TRAILS, COIN, IRIS, ASPEN, and morefor each of the different programs
for health and human services. These separate systems dont communicate
with each other and require duplicate data input. Knowing how many and
which different programs are serving a client or a family at any time is
complicated and difficult. So difficult, in fact, workers sometimes will not find
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out what the systems report and rely on the clients report, which may or
may not be the whole story. Because updating the systems requires data
input two or more times, the information is not fully reliable across all of the
different systems.
Broomfield has the same information systems and reporting
requirements as other counties. At a managers work session in late
October, one manager articulated, and the others agreed, we cant get to
integrated services delivery and integrated services consistency through the
state information systems. They have chosen to address the information
systems issues in two ways. They have modified a client contact system
called ACT to serve as a Broomfield-specific system that will track clients
and the services they receive. The ACT system was designed for use in
private industry, and health and human services personnel have worked
together with state and county information technology personnel and a
private software firm to modify it for use in Broomfield. It is intended to
package the data for reporting on services integration and then un-package
the data for reporting to the state on a program-by-program basis. It still
requires duplicate data entry, but the system makes connections between
the various programs and the clients who are served so the tracking and
reporting can be meaningful to the services providers and for the purposes
of integrating services.
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Another way that Broomfield is attempting to address information
systems issues is by applying to be a pilot county for the Colorado Benefit
Management System (CBMS). CBMS is an information sharing system in
joint development by the state Department of Human Services and the
Department of Health Care Policy and Financing to integrate the information
technology for eligibility systems. The system was originally intended to be
a smart system that could determine eligibility across hundreds of available
programs. That part of the system is not working and may not become
available. The objectives of CBMS are to replace existing legacy systems
with one system that will eliminate redundant processing, provide a single
point of entry for multiple eligibility programs, and improve access to benefits
and services for clients while increasing accuracy and consistency in
eligibility (CBMS Fact Sheet, 2002). Seven other counties have stepped
forward to participate with the CBMS pilot. The system is untested, and
being part of the pilot contains risks associated with more staff time and
effort without a known outcome. The Broomfield managers believe it is
important and necessary to show philosophical support for the development
of an integrated information system if they are serious about the
development of an integrated services system. Being part of the pilot is
intended to send that message to other counties and to the state.
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The New Department
During this study, two things were happening in Broomfield
simultaneously: creating a new department and implementing a new model
for services. Therefore, developing integrated services was an equal priority
with hiring, ordering equipment and supplies, finding space, and creating an
organizational structure. In fact, as the opening day of November 15, 2001,
drew near, developing the support structure for mandated services became
a higher priority than anything else. One of the participants said she was
feeling overwhelmed, and we didnt take into account the breadth of
everything that we would have to do to just start the county and how that
would impact what we are also trying to do with integration. Another added,
Integration is on the back burner for now, but, in the same breath,
expressed a concern that needing to function could become an excuse for
never doing it.
When the managers met together weekly, they discussed their to do
lists of what was needed in order to open the department and to provide
mandated services. This list didnt consistently include integrating services
and creating new programs and services. There was an obvious tension
between getting it done and doing it differently. The participants said there
would be a window of opportunity where being new would be an advantage
to building a new system, and at some point the window of opportunity
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would close. They were required to have services available by the opening
date, and the looming deadline influenced their activities and priorities.
The directors original plan had called for hiring the managers in
March and bringing the rest of workers on in June. However, the budget did
not include money for planning, staffing the department, working with the
existing city organization and outside agencies, and getting input from the
community before the department opened for business and began providing
services. In March, the director lamented,
I think we would have been much further had we actually brought
staff on to plan for integration, thought through some of it before we
had case loads. ... There was a lot of thinking about how we were
going to finance services and how were going to house services but
much less time about what does that mean in terms of how you do it.
The department managers and staff members have to plan and develop
integrated programs and services while they provide mandated services,
which is what any existing county must do. Since the department opened to
the public in November, the director said, theres no sort of time out while
they do this.
Building culture. At a Colorado State Board of Human Services
meeting in early January 2002, one of the commissioners said, It sounds
like you are not only building a new organization, but you are building a
whole new culture. The director responded, Yes, and its very difficult.
Later, she added, We are culture building with all of staff now. And we are
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