Coordinating Human Service Systems for the Vulnerable: Lessons from The Regina intersectoral Partnership (TRiP)

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 Public administration organizes policy areas into separate departments or silos for the sake of order and efficiency (Weber et al., 2009, 214)¹. This results in ‘departmentalism’ (Gulick & Urwick, 2003)², ‘tunnel vision’ (Rosenbloom & Rosenbloom, 1989)³, and ‘single purpose organizations’  (Bezes et al., 2013; Scott & Gong, 2021)⁴. Silos make it difficult to address complex pervasive public and social issues (known as wicked problems) that intersect multiple policy domains (Christensen et al., 2019)⁵. Silos’ inability to address these complex issues create negative outcomes, such as delayed decision-making, poor service delivery, duplication of resources, difficulties to collaborate with non-governmental stakeholders, and challenges with effective coordination and sharing of information (O'Keefe et al., 2007; Scott & Gong, 2021)⁶. Young people facing mental health problems, for example, experience the worst outcomes across quality-of-life measures. This is in large part because these youth require coordinated supports from multiple sectors, but do not receive sufficient care due to fragmentation, causing lack of access to existing services (Shaw & Rosen, 2013)⁷; Van Dongen et al., 2018⁸).

Multi-sector collaboration is one strategy to help coordinate services and address multifaceted policy challenges comprehensively and efficiently. The concept originated from the public health discourse in 1970s when the impact of non-health factors on health and well-being was recognized. In the public administration field, the focus of multi-sectoral collaboration has been on coordination mechanisms, processes of institutionalization and distribution of power, values and culture in government (Mondal et al., 2021)⁹. Various terms have been used to refer to collaboration among sectors, and for which many definitions have been proposed.

By multi-sector collaboration we mean  “the linking or sharing of information, resources, activities and capabilities by organizations in two or more sectors to achieve jointly an outcome that could not be achieved by organizations in one sector separately”(Bryson et al., 2006)¹⁰. It is an adaptation to turbulent, highly complex environments as a means to reduce uncertainty and promote organizational stability, and is usually in response to a “sector failure”, where a single sector has already attempted and fallen short of addressing a problem (Bryson et al., 2006, 45).

To meet the diverse needs of vulnerable children and youth, collaboration across various service delivery organizations is vital (S. M. Brown et al., 2014; Bunger & Huang, 2019; Colvin, 2017)¹¹. To provide comprehensive person-centred service delivery, these organizations should coordinate services through timely referrals and information sharing (Blanken et al., 2022)¹². Some benefits of multi-sector collaboration include faster access to healthcare, better coordination of services, shared knowledge, enhanced creative problem-solving, and improved outcomes (e.g., health, education) for children (Van Dongen et al., 2018, 14)¹³. However, multi-sector collaboration is not a certainty of success, as efforts might fail or even create additional problems (Kenis & Raab, 2020)¹⁴. Case studies of multi-sector partnerships have the potential to explain what strategies are most effective in using multi-sector collaboration to address wicked problems caused by fragmentation. Understanding how these collaborations are formed/structured, governed, and evolved is therefore crucial for the effective collaborative efforts in the future.

 

The Regina intersectoral Partnership (TRiP)¹⁵ is one such multi-sector collaborative initiative in Regina, Saskatchewan. Its focus is on improving outcomes for children and youth in vulnerable contexts through coordinated supports from various human service organizations. At TRiP, children/youth in vulnerable contexts are defined as hard-to-reach children and adolescents who are at risk of mental health disorders, crime, violence, school absenteeism, disruptive behaviour, and substance use issues. TRiP offers long-term case management for vulnerable children, helping them make and receive the appropriate connections and service referrals to address the challenges that they face. The benefits of providing long-term commitment and supports to vulnerable youth and their families is well-documented (Barton & Henderson, 2016)¹⁶. TRiP works with children under 11 years for an average of 19 months and with children above 12 years for an average of 14 months.

TRiP arose in 2008 out of a community-identified gap. It was championed by two leaders from the Regina Police Service and the Regina Public School Division, who were concerned about prevention and early intervention for youth exposed to risk factors making them more likely to engage in unhealthy behaviour. Two individuals from TRiP (former Superintendent, Regina Police Service and recent TRiP Coordinator; and the Crime Prevention Strategist, Regina Police Service) were tasked to conduct research and design an initiative to address this perceived gap.

In 2010, after 18 months of research and development, the Regina Police Service (RPS) formed a Steering Committee comprised of senior managers from the Ministry of Social Services, Ministry of Justice (added in 2015), Saskatchewan Health Authority (formerly Regina Qu’Appelle Health Region), Regina Public and Catholic School Boards, and the RPS, which continues to provide oversight and strategic direction to TRiP. The initiative was given further momentum when the Province of Saskatchewan released a document titled Building Partnerships to Reduce Crime (BPRC), calling on all parts of the justice system and human services to co-operate and combine their best efforts, resources, and expertise to reduce crime.

Another facilitating factor was the history/precedent of service integration in Saskatchewan. From 1994 to 1998, 10 Regional Intersectoral Committees (RICs) were established, followed in 2000 by the establishment of the Human Service Integration Forum (HSIF). The HSIF was an intersectoral initiative representing different ministries and human service organizations. The 10 RICs, each supported by a RIC coordinator, were located across the province and linked to the HSIF. The RICs provided a forum to liaise human service organization leaders within a designated region to communicate and formulate shared goals and priorities, shared indicators, evaluation frameworks and outcomes. TRiP built on these pre-existing multi-sector capacities and resources.

The Board of Police Commissioners for the City of Regina, on behalf of the Regina Police Service, became TRiP’s accountable partner in 2012, the same year it began receiving funding from the Ministry of Social Services. The Regina Public School Division has provided a dedicated office space for the initiative to work out of since 2015. In 2015, following a process review and record management system design, the referral tracking became consistently accurate. From 2015 to 2022, the average number of referrals per year was 120. The impact of COVID-19 resulted in a sharp decrease of referrals to TRiP. If 2020 and 2021 are removed, the average number of referrals increases to 131 per year, which more accurately reflects the current reality of TRiP (The Regina intersectoral Partnership (TRiP), 2022).

There is another multi-sectoral collaborative initiative in Saskatchewan called the Hub, which  differs from TRiP in approach. The Hub serves as a juncture between government human service agencies, where representatives meet regularly, share de-identified information to determine community cases with acutely elevated levels of risk, and mobilize resources to provide immediate and integrated responses to cases posing the greatest concern. In its original design, Hub does not provide support, case management or long-term follow-up outside of immediate response to acutely elevated risk, instead possessing a greater focus on information sharing (Nilson, 2016)¹⁷.

TRiP possesses a dedicated administrative infrastructure to intake and oversee children and youth cases with permission from their caregivers or legal guardians. This voluntary and consent-based approach is a unique feature of TRiP.

As a result of consent being signed, data sharing occurs among the stakeholders. Data is shared internally among stakeholders, which allows TRiP to direct individuals to the services most suited to their needs. Families would otherwise have to navigate the human services systems themselves and apply with each service provider independently. It also has the added benefit of ongoing relationships with external community partners, who offer youth the opportunity to participate in various pro-social activities.

TRiP’s process consists of 6 phases. A young person can be referred to TRiP when there are detected behaviours or conditions that make the individual vulnerable. Considerations for referral include when a child/youth exhibits multifaceted behavioural challenges; is showing or is affected by composite risk factors; has not benefited from previous engagements with services; has experienced personal, situational, and/or institutional barriers to services or supports; and that other options have been explored before approaching TRiP.

Upon referral, within 72 hours an Intake and Referral Officer (IRO) works to establish contact with the family to discuss with the family the source and reason for referral, explain the initiative, obtain verbal consent from the family, and set a date to meet and provide written consent. When the IRO obtains verbal consent, the referral’s name is shared with internal stakeholders via email to begin reviewing their respective systems for historical and current information in preparation for the intersectoral Collaboration Team (iCT) presentation. Once the IRO connects with the caregiver, they complete the in-depth Caregiver Intake Guide (approximately 1.5 hrs to complete) while the IRO separately conducts a Child and Youth Guide, a questionnaire completed specifically with the young person (approximately 45 min). Simultaneously, a school board liaison from the appropriate school board completes a school background report, which involves a phone interview consisting of structured questions to school personnel (administration, teacher, counsellor, support personnel).

Once all of the background information is collected, a presentation at the weekly iCT meeting occurs.  At the iCT meeting, information collected from the Intake Guides, and Stakeholder Background Reports is presented.  From this presented information and stakeholder expertise, the Risk Based Needs Assessment Tool is scored.  This becomes one of multiple factors in the decision of whether or not a referral is accepted. If accepted, the referral agent, caregiver and any other involved partners are advised that a TRiP Liaison has (or will be – if there is a waitlist) reaching out to begin setting up a plan.

For the duration of a file being open, a case action plan is developed and continuously revisited; actions and milestones are set among the child/youth, caregiver and involved supports, Coordinated Custom Case Conferences (C⁴) occur every 4 – 6 weeks to facilitate progress and respond to changing needs as necessary, and to-do/action assignments are given to all participants. TRiP will remain involved with a child/youth until there is a point of mutually agreed upon stability, at which time there is a transition plan put in place and TRiP will close the file.  Other reasons for file closure include: lack of engagement from the caregiver, refusal to attend school, leaving the City of Regina, or a change in status with the Ministry of Social Services. To understand the impact that TRiP has, the following vignette (In Box 1) provides a summary of Victoria’s experience of TRiP engagement, which is typical of TRiP clients.

Box 1: Victoria (fictitious name) Story (Source: Nilson, 2017) Twelve-year-old Victoria was referred to TRiP by her Principal with concerns including: associating and possibly joining a gang; negative peers; exposure to drug use; confrontations with peers and adults; oppositional behaviour; lacking the ability to develop healthy relationships, taking pride in intimidating others; and expressed a desire to harm peers and herself. At eleven, she was arrested after stealing and crashing a vehicle. In the home environment, Victoria was exposed to drug and alcohol use as well as domestic violence. Victoria’s biological father left and other father figures were in and out of her life. Tragically, at eight she lost a close friend to suicide resulting in a significant traumatic impact on her. Following the extensive intake and acceptance process, TRiP’s team mobilized supports and services via case conferencing and intensive case management. Connections made included her attending various pro-social outings with the School Engagement Worker (SEW); attending a fitness facility, boxing classes, museum visits, baking classes and attending the Regina Police Service Showcase. Victoria was also provided the opportunity to attend guitar lessons, a basketball skills development camp, and was connected to private counseling services. The SEW attended events that Victoria participated in including her basketball games, track and field, and grade 8 graduation where she received awards for literacy and junior leadership. TRiP’s School Liaison and SEW maintained regular contact with her mother, and school personnel over a number of months which resulted in her being surrounded with a support system that encouraged her to continue to make healthy life choices. Her involvement in pro-social activities strengthened her confidence and social skills. Victoria’s attitude toward education changed resulting in increased engagement and achievement at school.  Since involved with TRiP, there has been no police contacts and her situation was stabilized. TRiP continued to be involved over the summer and concluded her file after a successful transition to high school.

TRiP itself does not offer services directly to clients, but connects clients with programs and services offered by its internal stakeholders and community partners. These supports can be separated into three different categories.

1. Services offered by its stakeholder agencies: the Ministry of Social Services, Ministry of Justice, the Saskatchewan Health Authority, and the School Divisions. These include therapy, addictions, and counselling services, and specialized services such as hoop dancing and smudges.
2. Programming offered by community-based organizations partnering with TRiP, including the YWCA and YMCA, Dream Brokers, the Autism Resource Centre, Regina Open Door Society. The Saskatchewan Science Centre and the University of Regina.
3. Government strategies and initiatives such as the Cognitive Disability Strategy, Complex Needs Protocol, and the Early Years Family Resource Centres.

Over the years, there have been several independent evaluations of TRiP activities. These evaluations show areas in which TRiP has been successful and where it needs improvement.

For instance, evaluations from 2012 and 2015 showed a significant reduction in risk and police contact for children under 11 engaged with TRiP. Another evaluation conducted by Chad Nilson (2017, 84) found that there was a direct reduction in personal, situational, financial, and systemic barriers to service access, community engagement, and support during their time with TRiP. This evaluation shows that of children/youth engaged with TRiP, 94% have maintained, improved, or achieved good school attendance following support services received. On the service delivery side, staff of participating human service agencies expressed the view that TRiP improves collaboration, reduces role confusion, improves efficacy of collective action, and increases accountability of agencies for client outcomes (Nilson, 2017, 85)¹⁸.

TRiP also faces its own challenges. A key challenge similar to other multi-sector collaboratives, is around evaluation, as TRiP lacks a standard measure to assess impacts and shared outcomes. Although TRiP data collection policies allow for measuring shared impacts on children and families, it does not have established tools and methodologies to do so. TRiP not only wants to identify outcomes, but also determine whether they are the direct result of the collaboration. Finding a way to separate shared or collective outcomes from individual outcomes of each sector (e.g., education, mental health) in collaborative initiatives is an under-researched area.

Another major challenge facing TRiP is chronic underfunding. Over the last 13 years, TRiP has been struggling to attract funding, especially from government stakeholders with mandates TRiP is addressing through the innovative and effective collaborative framework they function within. In the absence of a cost analysis (e.g., cost-benefit, cost-effectiveness), TRiP has found it challenging to provide robust evidence of the return on investments to convince governments for more funding.

The term Collective Impact was first articulated by John Kania and Mark Kramer in 2011 in the Stanford Social Innovation Review (Kania & Kramer, 2011)¹⁹. Collective impact is an approach or framework to achieve systems-level changes in communities through coordinated multi-sector collaborations (Pearson, 2014)²⁰. It is a disciplined and structured approach to problem solving that takes place when a group of actors/stakeholders from different sectors commits to a common agenda for solving a complex social problem. Collective impact has gained widespread uptake in a wide range of contexts such as poverty reduction (United Way uses a collective impact approach), homelessness, substance abuse, maternal health and child care, community health and wellbeing, Indigenous health, health equity, and healthy aging. The collective impact approach includes five core elements: a common agenda (shared purpose), a shared measurement system, mutually reinforcing activities, continuous communications, and a backbone infrastructure (Kania & Kramer, 2011) (See Box 2 for definitions).

Box 2: Five Core Elements of Collective Impact A Common Agenda (or shared purpose): All sectors and organizations have a shared vision for change, a common understanding of the problem, and a collective approach to solving the problem through agreed-upon actions. A Shared Measurement System: Data are systematically and consistently collected and reported on a set of collective indicators across all sectors and organizations in order to continually evaluate progress and encourage learning and accountability. Mutually Reinforcing Activities: Although the activities of different sectors and organizations must be differentiated, these should be coordinated through a mutually reinforcing plan of action. In other words, while different sectors and organizations play different roles in the collaboration, their activities must be linked to the common agenda determined collectively. Continuous Communication: Ongoing and open communication is required across all organizations and sectors in order to build relationships, trust, shared vocabulary, and ensure mutual objectives. Backbone Support Organizations: Collective impact initiatives require dedicated members with specific set of skills to coordinate organizations and sectors.

 

 

TRiP reflects the practices and principles of collective impact. TRiP team or backbone group consists of 13 individuals representing 6 stakeholder organizations, Jordan’s Principal, and TRiP contract employees who are centrally housed in a shared office setting at the Regina Public School Division. As TRiP staff come from different sectors, they are governed by the privacy frameworks, disclosure practices, safety protocols, confidentiality standards, and policies and procedures of their respective sectors and mandates. However, all sectors work toward a shared purpose to enhance wellbeing and healthy development of children and youth (i.e., a common agenda). The backbone team uses various communications mechanisms including onboarding orientation, weekly team meetings, an annual process review, and procedure review (i.e., continuous communications) to coordinate support services across sectors (i.e., mutually reinforcing activities). TRiP is currently working on designing a shared measurement system with a number of other collaborative initiatives focused on vulnerable populations across Canada under the leadership of Dr. Chad Nilson of Living Skies Centre for Social Inquiry, which is a research, evaluation, and advisory firm with expertise in multi-sector collaborative initiatives designed to improve community safety and well-being.

TRiP presents a potentially scalable model for other jurisdictions, levels of government, and areas of public policy to coordinate, streamline, and increase uptake of services that currently remain underutilized due to fragmentation.

To improve scalability of initiatives such as TRiP, economic evaluations play an important role in informing policy and decision makers on the trade-offs in costs and benefits or effectiveness of such initiatives (Brundisini et al., 2021)²¹. Repeated economic analyses have confirmed that investment in young children supports economic development with an estimated economic payback as high as $16 for every $1 invested (Grunewald & Bezruki, 2012)²². Although, there has been no economic evaluation (e.g., cost effectiveness, cost-benefit) conducted at TRiP, this is an area of focus for TRiP and its stakeholders to conduct a cost analysis.

Successful multi-sector collaboration is precarious and relies on numerous variables lying within and without the individual and collective point of control of the collaboration’s stakeholders. Exogenous factors threatening the sustainability of multi-sector collaboration include institutional forces (changes in funding priorities, policies), shifting interests, and problems of trust between individuals within the partnership (Bryson et al., 2006). Other barriers include under-valuing partners, imbalances in power, and disparities between organizational capacities of different sectors (Fortier & Coulter, 2021, 147)²³.

TRiP has been ongoing for 13 years and so presents an opportunity not only to learn about the factors involved in formation of partnerships, but also those that are critical for promoting the future of existing partnerships. Potential factors researchers have associated with sustainability of collaboration include the existence of champions to promote and funnel resources toward the partnership, the presence of formal accountability and evaluation mechanisms, alignment on objectives, and good-quality relationships between stakeholders (Bryson et al., 2006, 52; Stål et al., 2022, 446 ²⁴; Ward et al., 2018²⁵). It will offer valuable insight for policy research to learn which of the identified factors are present in the case of TRiP and whether factors outside of existing literature that have contributed to the longevity of the partnership can be identified.

 

Given the difficulties forming and sustaining multi-sector collaborations due to coordination challenges and conflicting interests of the sectors involved, we decided to use TRiP as an in-depth case study to investigate how collaborative initiatives work. We received funding from CIHR (Canadian Institutes of Health Research) to evaluate the TRiP initiative. This project aims to investigate the emergence/formation of multi-sectoral collaboration, patterns of collaboration, factors influencing multi-sectoral alliances and service coordination across sectors, and processes and structures involved in building and maintaining a strong multi-sector cooperation. We will examine the governance, organization and delivery of coordinated services across sectors, funding structure, and accountability mechanisms within TRiP. We will provide a rich and detailed description of TRiP functions and features that will enhance transferability of our findings to other settings (Bryman, 2012)²⁶.

Over the course of one year we will conduct a formative process evaluation of the TRiP initiative (Brandon & Sam, 2014²⁷; Humphrey et al., 2016²⁸). Our evaluation will investigate how TRiP operates to achieve its intended outcomes. Our evaluation will not focus on evaluating if TRiP initiative works as a multi-sector collaboration compared to silo systems (i.e., impact and outcome evaluation). Rather, we seek to generate insights and learning that can be applied locally and nationally to similar collaborative initiatives. By drawing on interviews with stakeholders from different collaborating sectors and persons with lived experience as well as facilitated activities (i.e., World Café, Nominal Group Technique (NGT)²⁹, observations, and document reviews, the research team will identify factors influencing collaboration and service coordination across sectors and its sustainability over time.

We hope findings from this project can guide the implementation of context-driven strategies to sustain and maximize the impact of collaborative efforts across sectors. Our research findings will have policy implications for the ministries of health, social services, justice, as well as police services and schools to better plan for effective and efficient coordination of services across sectors. These lessons and recommendations could be scaled up and adopted as good practices in other ministries. There will be system-level policy lessons for improving coordinated service delivery across health and other human service organizations in Saskatchewan and Canada, and ultimately improved health outcomes among children/youth. A recent report from Canada’s Chief Public Health Officer calls for finding new ways of collaboration across sectors (Public Health Agency of Canada, 2021). Our findings will respond to this call and help find new ways that integrated delivery systems can address social determinants of health. Findings will also inform policy around the design and implementation of collective impact, which is gaining traction and widespread uptake in the Canadian health system.

JSGS Policy Brief Series

We acknowledge the funding provided by the Canadian Institutes of Health Research (CIHR) grant No. 187045, and Saskatchewan Health Research Foundation (SHRF). Akram Mahani is supported by a CIHR Catalyst Grant: Policy Research for Health System Transformation.

Akram Mahani is an Assistant Professor at the Johnson Shoyama Graduate School of Public Policy (University of Regina campus) who studies multi-sectoral collaboration to improve population health outcomes, healthy cities and communities, and healthy public policies. She has received funding from CIHR to investigate cross-sectoral collaboration to improve outcomes for children and youth in vulnerable context. She has also received funding from SHRF (Saskatchewan Health Research Foundation) Align program to examine how health is integrated into urban design and urban planning decision and policies.

Matthieu Petit is a Master of Public Policy student at Johnson Shoyama Graduate School of Public Policy. He uses philosophical perspectives drawing from existentialism and phenomenology to explore issues of disability and accessibility legislation in Canada. He has worked for Employment and Social Development Canada in the area of emergency management and Prairies Economic Development Canada in people and talent management.

Wendy Stone is the Crime Prevention Strategist with the Regina Police Service and is dedicated part time to The Regina intersectoral Partnership (TRiP) team.  With a strong belief in community engagement, her 26 year career has focused on long-term, multi-sectoral, collaborative approaches designed to impact and improve social issues.

Lance Dudar is a retired Police Executive who has spent 28 years at the Regina Police Service, achieving the rank of Superintendent. Lance has spent the last nine years as the Coordinator of The Regina intersectoral Partnership. A large part of Lance’s work career has focused on creating opportunities and improving the safety and wellbeing of marginalized populations. 

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