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What Our Communities Are Teaching Us

What our Communities are Teaching Us

With three AmericaServes markets up and running – NYServes-New York City, NCServes-Metrolina and PAServes-Greater Pittsburgh, and two more underway – NCServes-Raleigh-Durham and SCServes-Low Country, we’re observing and documenting the value that these deployed and tailored collective impact initiatives are having upon their respective communities, and their ability to best support transitioning servicemembers, veterans and their families.

Lauded as one of the more transformative approaches being undertaken to engineering Public-Private Partnerships (P3) in the veteran sector, AmericaServes coordinated networks of services, resources, and care represent not only leading innovation fueled by technology and dynamic human capital, but also represent the single-greatest means by which to collectively best serve America’s transitioning servicemembers, veterans, and their families.

Built upon the foundation of a ‘the sum of its parts’ value proposition, AmericaServes communities leverage the robust resources made available by the Department of Defense (DoD) and Department of Veterans Affairs (VA) together with the best community-based nonprofit and human service organizations to field coherent networks organized and fielded specifically to serve the ongoing needs of America’s servicemembers, veterans and their families. Within each of these communities, providers and practitioners from each of their respective platforms of service (i.e. housing, legal, health, employment, etc.) are working together, through coordination, in ways many thought were not possible across these previously inaccessible and fragmented points of service delivery.

Funded entirely by the private sector for their initial two years of operation, AmericaServes communities operate as accountable coordinated networks capable of navigating and connecting individuals and their unique needs to matched resources, services, and care within and even outside the network’s ecosystem. Adopted from care coordination models and evidence coming to market through the transformation underway in health care practice, organizational providers and practitioners are ‘joined’ together in a network specifically organized and deployed to efficiently address the needs of its members. Most importantly, AmericaServes has introduced process, protocol, and tracking into local communities to underpin their network’s activities.

Revolutionary in its collective identity, Case Managers and Social Workers across once-disparately organized and resourced organizations operate instead collectively, as a team, with higher levels of trust and confidence in one another, because for the very first time they see in near real-time one another’s efforts to serve individual’s needs through AmericaServes’ unique use of technology and data to help them address the needs of individuals turning into these networks for assistance. A true and comprehensive picture of coordination is unfolding and its value is proving itself in light of the outcomes being achieved across AmericaServes communities.

What we’re learning from communities across the country has the potential to not only shape the future of service delivery for servicemembers, veterans and their families itself, but equally important, standards by which to serve them by for generations to follow. Today’s AmericaServes communities are embracing discontinuous change in the interest of positioning their resources in more easily accessible and navigable ways to ensure our transitioning servicemembers, veterans, and their families obtain the support necessary for successful transition into their communities. That change is revealing itself through the following key insights:

Providers like ‘smart’ referrals – At the outset of designing the AmericaServes platform and model, many providers shared their frustration with the lack of trust and confidence in each other. Providers tend to keep their trusted fellow providers near, and avoid working with those they do not know or trust. Therefore, it was not a surprise to us when at the onset of designing the AmericaServes model, providers challenged us to design a network that would support placing greater trust and confidence in one another, whether they have worked with each other in the past or not. To providers, creating an ability to trust all other providers in the network has proven to be one of the early ‘wins’ in AmericaServes communities. As an AmericaServes provider, having the capability to knowingly introduce individuals to points of service beyond your own organization’s boundaries (and have that measured in real-time in terms of the referral’s accuracy, timeliness, and outcomes achieved), has become the new basis by which AmericaServes providers assess their relationship with their fellow providers. As a result, we have elevated the discussion of outcomes beyond the anecdotal and often biased perspectives of fellow providers.

AmericaServes Referral Process

Importantly, AmericaServes communities measure their ability to coordinate access to network services in three dimensions:

  1. Accuracy – was the referral made a smart referral to a provider that can serve the individual’s needs?
  2. Timeliness – was the referral made actioned by the receiving organization in a timely manner to address the individual’s needs, in priority?
  3. Impact – did the referral result in the individual’s needs being met?

Within this approach to measurement and evaluation, AmericaServes communities survey every individual’s ‘satisfaction’ with services received through thirty-day, post-service surveys to ensure services being sought are in fact being secured in meaningful and impactful ways. This triad of measurement – accuracy, timeliness and impact – result in an accountable ecosystem capable of keeping providers abreast of important and key progress being made by their clients throughout the network, regardless of whether or not the services originate or terminate with different providers. Transformative in its approach, AmericaServes communities are connected and accountable to those they serve at all times.

NCServes Referral Ratio

Transitioning Servicemembers, veterans, and their families get help with their principle challenge: navigating complex systems of care and service through eligibility pre-determination. Said simply, the value coordination is playing in the eyes of those transitioning servicemembers, veterans, and their families is that credentialed staff are knowingly – and on a pre-determined basis – matching individual’s needs with organizations eligible to provide them with services and care. Perhaps more than any other feature, proactively matching specific needs with network providers prior to the point of service delivery, is at the heart of AmericaServes value proposition. In each market, AmericaServes Coordination Center Staff ‘work-up’ eligibility so that individuals are matched with organizations capable of addressing their needs before they show up at the provider’s door to be served. Hugely beneficial to individuals seeking services, eligibility ‘pre-determination’ has shown incredible value in terms of reducing attrition associated with blind, point-to-point referrals. AmericaServes reduces frustration by individuals used to being turned away from services because they were deemed ineligible for the services being offered, and provider ignorance associated with making referrals in day-to-day fashion outside AmericaServes models of care and services.

Integrating VA and DoD platforms of services and care in AmericaServes networks not only backs up the train, it connects the stations along the way – Positioning our community resources and services prior to transition from military service is paying huge dividends for DoD and its associated military branches. Led by the efforts of the United States Army, DOD has entered into a partnership with AmericaServes networks and communities to ensure separating servicemembers and their family’s access community-based services and care in an integrated fashion. Staff from Soldier Family Assistance Centers (SFACs) and Transition Services are in fact Network Providers within AmericaServes communities – now equipped with the capacity to connect soldiers and family members with their communities and its resources while they continue to serve their country and as they prepare for separation. Key to understanding the benefits of doing so, trying to connect with community-based services following separation and navigating through the overly complicated eligibility criteria that comes with has become the bane of every veteran’s existence. In AmericaServes communities, we remove that principle barrier by coordinating access to points of service delivery within the network on behalf of all the individuals being supported by the network itself. A game-changer, by on-boarding the VA’s Social Workers, Eligibility Specialists and Benefits Advisors into the AmericaServes network design through Memorandum of Understandings, we’ve integrated what most thought was never possible: an accountable and transparent referral relationship built on coordination between providers from the public sector (VA) together with their nonprofit counterparts from within their community. At every step of the way in a soldier’s journey, AmericaServes communities support an integrated and connected overlay of support and resources to better-serve their needs, and the needs of their families.

AmericaServes Book Tour

Data doesn’t lie: Co-occurring issues are real issues amongst transitioning servicemembers, veterans, and their families – For every unique individual being served through an AmericaServes community, greater than 72% have multiple issues underpinning their needs. Said another way, for everything unique about the experiences of individual servicemembers and their families, there is one unifying theme: they have overlapping needs. Housing and financial assistance needs show a strong correlation with the need for legal services amongst individuals seeking assistance from AmericaServes networks. Serving those overlapping needs well plays to the absolute strength of the AmericaServes model: a unity of effort brought about through coordination amongst differently organized providers. In most communities, addressing these three overlapping needs would result in organizations somewhat blindly sending individuals to three different points of service delivery in their community with no trace left behind as to what was accomplished. In AmericaServes communities, each of those three service providers along the way ‘knows’ what the other service provider has accomplished thanks to the providers being networked together and sharing sufficient information regarding the progress each of them has made while ‘serving the whole’ (all while maintaining personally identifiable information and HIPAA compliance).

Service Requests

Speaking of data, ‘say goodbye to the anecdote’ – Data has become the new, valued currency traded in AmericaServes communities and anecdotes are becoming relics of their past, overly exposed life. Insight into what impact AmericaServes communities are having upon those they serve is being driven by strong measurement and evaluation built on a foundation of data sets that are accessible to each participating provider within the network, and to the network itself. Telling the story of what it looks like to make referrals within AmericaServes networks is a straightforward proposition since every network transaction is uniquely date/time-stamped. AmericaServes communities measure process, efficiency, and efficacy of network activities throughout the lifespan of services being delivered. In addition and thanks to its electronic archival capability, every transaction and outcome is preserved. This benefits individuals returning to services after being effectively served the first time so that they can begin their subsequent service journey where they left off, and therefore are not ‘starting over’ as is the case in a majority of this country’s approach to delivering human services. Revolutionary in its approach, an individual’s service history can remain unbroken no matter how many times they may return to an AmericaServes network for assistance. Analogous to the service history maintained by your car dealer, every time you go in for a tune-up, the data collected from that tune-up is recorded. Think of AmericaServes networks in a similar fashion; when you show-up for a personal ‘tune-up,’ your service history within the network shows up with you. Lastly, AmericaServes communities capture post-service survey data to better inform the subsequent delivery of services and resources while ensuring services delivered achieved their intended aim.

NYServes Survey

As AmericaServes networks continue to be built and deployed around select communities, the team behind them is committed to ensuring we learn from our communities along the way. Continuous learning will always underpin the AmericaServes model to ensure the best possible practices are applied to serving the needs of America’s transitioning servicemembers, veterans and their families.

What our Communities are Teaching Usby Colonel (Retired, U.S. Army) Jim McDonough, Managing Director, Community Engagement and Innovation, IVMF, Maggie Pollard, Manager – Health & Public Service, Accenture, and Dan Brillman, CEO, Unite US

Jim McDonough is a Managing Director at the IVMF. A retired Army Colonel, Jim has served in various public, nonprofit and philanthropic roles prior to joining IVMF

Maggie Pollard leads Accenture’s partnership with the IVMF as part of the company’s Skills to Succeed corporate citizenship initiative, which aims to equip 3 million people by 2020 with the skills to get a job or build a business. An Air Force veteran, Maggie has supported IVMF since the inception of NYCServes and expansion into AmericaServes.

Dan Brillman is the CEO of Unite US, the technology platform powering AmericaServes. An Air Force Reserve pilot, he has developed and expanded community’ utilization of technology to better serve military families.

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