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Comprehensive Community Needs Assessment

Broward County Human Services Department

Executive Summary

Public Works LLC • June 16, 2014

www.public-works.org

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EXECUTIVE SUMMARY

Broward County is unique compared to other counties in Florida, and in fact, compared to many counties throughout the United States. An extensive array of health and human service programs support its most vulnerable citizens, taxpayers provide funds for primary health services and children’s programs, county leadership funds programs that are needed to fill the gaps, and the existing infrastructure fosters the concepts of collaboration and cooperation.

Even with this array of services and funding, county leadership recognizes the job is not done. Many county residents continue to struggle with basic needs, including those who are homeless and those who need mental health or substance abuse services. There are fragile children and families fighting to remain together and individuals and families who need to be reintegrated into the community after incarceration or intensive residential behavioral health treatment.

County leadership recognizes that they must be good stewards of public money and ensure funds are 1) used most efficiently and effectively; 2) targeted to the areas of most need; and 3) produce outcomes that meet the goals and objectives of service. And all of this must be provided in an environment that is continually changing as a result of state and federal policy and funding reforms, and changes in the types of services needed to address increasingly complex issues facing individuals and families.

The Broward County Human Services Department (HSD) engaged Public Works to conduct a comprehensive needs assessment to address these questions: 1) What is the current state of funding and delivery of health and human service programs?; 2) How must programs adapt to meet changing and unmet service needs?; and 3) How must the county system change to improve its delivery of services throughout the community?

This report, A Comprehensive Human Services Needs Assessment, is intended to be a starting point for long-term strategic planning. This Executive Summary provides an overview of the findings and recommendations that are contained in the full report.

Methodology. Public Works conducted the following data collection activities:

• Performed a thorough investigation of documents, reports, data, and strategic plans developed by organizations throughout the county over the last several years. We reviewed 25 existing needs assessments and strategic plans produced by funders, advocates, planning organizations, and advisory boards.


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In addition, we reviewed pertinent state statutes and local ordinances, annual reports, business plans, and program and organizational reviews completed in the last five years.

• Conducted hundreds of hours of interviews and on-site visits with key HSD managers and staff, stakeholders, county leadership, providers, advocates, and other organizations that are part of the health and human services community in the county.

• Compiled program and spending data with emphasis on county funds allocated to programs.

• Developed insights and opinions through several primary data collection methods including:

• Provider Town Meeting – Twenty-seven providers attended a half-day session on January 15, 2014. Breakout groups – Health Care, Behavioral Health, Children’s Services, and Criminal Justice – discussed current services, identified gaps in services, adequacy of resources, priorities for funding, collaboration efforts, and the relationship of providers with HSD.

• Provider Electronic Survey – An on-line survey was sent by email to 363 providers, funders, advisory board members, foundation representatives, and county and state agencies. One hundred thirty-three respondents completed the on-line survey (36.7 percent response rate) designed to gather information on current services, resources, gaps, changes in populations served, and services offered over the last few years.

• Resident Telephone Survey – Public Works’ subcontractor, Lake Research Partners, a national firm with significant experience in public opinion survey design, conducted a telephone survey of residents in targeted zip codes with high density elderly and low income residents from February 10-15, 2014. The telephone survey was completed by 415 adults residing in the targeted zip codes; 34 percent of respondents were reached on cell phones. The survey solicited information from residents who have received services, as well as those who have not.


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• Three Consumer Focus Groups – On March 12, 2014, three groups of consumers participated in focus groups organized by: consumers receiving services through Family Success Centers (seven participants), consumers receiving services through the Broward Addiction Recovery Center (BARC) (seven participants), and consumers receiving mental health services either for themselves or a child/family member (12 participants). Each 90-minute session solicited group participants’ opinions on their need for services, process for accessing services, quality of services and responsiveness of staff, satisfaction with services received, and suggestions for improvements.

Demographic Profile. Highlights of demographic data collected for this needs assessment show that Broward County faces several unique challenges, as evidenced by the following:

High Cost of Living:

• The total cost of living index in Broward County ($114.12) was higher than the state average ($100) and the cost of living in Miami-Dade ($90.93) and Monroe counties ($91.78) (2011). Source: Broward Regional Health Planning Council, Chapter 1: Regional Profile – Cost of Living and Florida Department of Health 2010 County Profiles.

• 62 percent of renters in Broward County are housing-burdened (spending more

than 50 percent of income on housing). Source: Broward County Housing Needs Assessment.

Diverse Population:

• Broward County was the third most ethnically and racially diverse county in Florida in 2010 (behind only Hendry and Orange Counties). In 2011, its population was 64.3 percent White, 27.0 percent Black/African American, and 25.8 percent Hispanic. Source: US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

Relatively High Levels of Poverty:

Poverty as defined by the U.S. Department of Health and Human Services includes: single individual with income less than $11,670; family of two less than $15,730; family of three less than $19,790; family of four less than $23,850; $4,060 for each additional individual.


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• Between 2007 and 2011, an average of 29,647 (12.2 percent) of persons 65 or older lived in poverty; a higher rate than statewide (9.9 percent) or nationally (9.4 percent). Source: US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

• 14.8 percent of Broward County residents lived in poverty (2011) – 20.4 percent

of those under 18, 12.4 percent or 82,392 households, and 17.2 percent or 78,640 children. Source: US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

• 49.9 percent of households with children report food insecurity with moderate to

severe hunger. Source: Broward Regional Planning Council, Hunger Survey: Food Security Report, 2007.

• 8,337 Broward County households were headed by 12,500 grandparents, of

whom 18 percent were below the poverty line and 24 percent of these households had no parent present (2011). Source: US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

Insufficient Affordable Public Transportation:

• The public transportation infrastructure in Broward County is smaller than that of other cities of comparable size with 320 fixed route buses, 76 community buses, and no rail system in 2014. Source: Broward County Transit Development Plan FY2014-2023 and US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

• Only 2.9 percent of Broward County residents use public transportation to go to

work compared with five percent nationally. This rate is slightly higher than for all of Florida that is at 2 percent. Source: US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

• Broward County workforce has a slightly longer commute to work (26 minutes on

average) than commuters in Florida as a whole (24.6 minutes) or nationally (24.3 minutes). Source: US Census Bureau, American Community Survey, 2012 Data Release, December 2013.

Concerns about Access to Health Care:

• Florida (24.1 percent) and Broward County (25.9 percent) had higher rates of uninsured than the United States (17 percent). Adults ages18 to 64 had the highest uninsured rate in Broward County (28.7 percent); 11.4 percent of children are uninsured. Source: U.S. Census Bureau, 2012 Small Area Health Insurance Estimates Note: Percent does not include ACA enrollment which is not yet available by county but will decrease this number.


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• Broward County has a lower ratio of licensed physicians (289.3 per 100,000 population) than the state (342.0 per 100,000 population). Source: Source: Florida Department of Health in Broward County, Community Health Needs Assessment, June 2013.

• Broward County has one-third of its census tracts and 10 low-income population groups designated as Medically Underserved Populations. Source: Broward Regional Health Planning Council, Broward County Health Plan, May 2013.

• Broward County had about twice the rate of HIV/AIDS and syphilis than Florida

as a whole. About 17 percent of persons living with HIV/AIDS in Florida resided in Broward County in 2011, although the county has between 9 and 10 percent of the state’s population. Source: Florida Department of Health, Broward County Community Health Assessment, June 2013.

Current Community Capacity and Delivery System. Public Works provides a first-ever look at countywide social services funding and analyzed data from the following major funders:

• Aging and Disability Resource Center of Broward County (ADRC) • Broward Behavioral Health Coalition (BBHC) • Broward County Human Services Department (HSD) • Broward Sheriff’s Office (BSO) • ChildNet (CN) • Children’s Services Council (CSC) • Community Foundation (CF) • Early Learning Coalition (ELC) • Florida Department of Children and Families (DCF) • Housing & Homelessness Funding • Jim Moran Foundation (JMF) • United Way of Broward County (UW)

These 12 funding sources account for approximately $515.4 million in health and human services spending. In the following chart, total funding is identified as well as funds transferred to other funders in order to eliminate duplication as much as possible. For example, BBHC provides funding to HSD. To reduce the incidence of double-counting, funding that was provided from BBHC to HSD is accounted for in HSD’s total and deducted from BBHC’s total. In this way we are able to be consistent in identifying which agency ultimately distributes the funds.


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Funder Total Funding

Identified (in millions)

Total Funding Minus Transfers to Other

Funders (in millions)

% Total Net of

Transfers

Housing – Housing Authorities $137.2 $137.2 27%

HSD $104.9 $103.6 20%

Early Learning Coalition $72.3 $72.3 14%

ChildNet $62.6 $62.6 12%

Children Service's Council $51.7 $44.7 9%

BBHC $42.9 $38.4 7%

Broward Sheriff’s Office $27.3 $27.3 5%

Housing – Federal Funds $21.3 $13.5 3%

ADRC $14.9 $8.0 1%

United Way $4.1 $3.5 1%

Community Foundation $3.2 $3.2 1%

Jim Moran Foundation $0.5 $0.5 <1%

DCF $124.2 $0.4 <1%

Housing – State $0.3 $0.2 <1%

Total $667.4 $515.4 Note: The following funders are not included in the chart above: North and South Broward Hospital Districts; individual cities; the Broward Health Department/Florida Department of Health; the Broward County Public School District; and funds received by non-profits through individual agency fundraising or donations. There are seven major categories of services funded through the 12 funders noted above. Just over three-quarters of all identified funding is in two categories: Children and Family Services (43 percent) and Housing and Homeless programs (32 percent).


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Countywide Service Categories (in millions)

Children and Family Services $219.4 43%

Housing and Homelessness $171.9 33%

Health Care $38.5 7%

Adult Behavioral Health $33.4 6%

Adult Addiction Services $21.6 4%

Basic Needs $18.2 4%

Senior Services $12.2 2%

Total $515.4 We also conducted an analysis of HSD programs and services to show the capacity of the department to provide grant funding in the community. The analysis, which does not include administrative funding, shows that the department’s General Fund budget has declined 13 percent since 2008. During this period, staff levels declined at a greater rate, from 382 positions to 282 (26 percent).

HSD Total GF Funding – 2008 – 2014 (in millions)

Fiscal Year

Total General Fund % Change $ Change Positions Percent

Change Position Change

2008 $80.6 382

2009 $78.8 (2%) ($1.8) 350 (8%) (32)

2010 $72.4 (8%) ($6.4) 279 (20%) (71)

2011 $69.1 (5%) ($3.3) 273 (2%) (6)

2012 $69.1 0% 0.05 272 0% (1)

2013 $69.9 1% 0.8 290 7% 18

2014 $69.9 0.01% 0.01 282 (3%) (8)

Total Change (13%) ($10.7) (26%) (100)

Note: The budget data in this table are from adopted budgets which do not include budget modifications made during the fiscal year. Also, in order to capture consistent budget items in the HSD budget now and over time, the table above does not include major one-time funding changes that occurred due to a restructuring or a transfer of a budget line item to other accounts. For example the Medical Examiner Office was moved from HSD to a different county department


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in FY 2010; funding is removed from all budget years so that the reduction does not skew comparisons. General Fund appropriations make up almost half of the HSD budget (49 percent or $71.5 million). Federal funds constitute 22 percent of the budget ($32.2 million) and state funds make up 11 percent ($15.5 million). The department is also appropriated $26.3 million in pass-through funds for financial management purposes, over which it has no control. Pass-through funds are comprised of $23.4 million in state Medicaid funds, $1.9 million in Pay Telephone Trust Fund monies, and $950,000 in Driver’s Education Safety Trust Fund monies.

DHS FY 2014 Budget by Fund Source (in millions)

General Fund $71.5 49%

Federal Funds $32.2 22%

State Funds $15.5 11%

Pass Throughs $26.3 18%

Total $145.5

HSD funding is allocated to the following service categories.

HSD Funding by Service Category – All Funds (in millions)

Service Area Contracted Services* Direct Services Total Spending

Percent of Grand Total Spending

Health Care Services $29.9 $3.3 $33.2 32%

Housing and Homeless $17.5 $1.2 $18.7 18%

Children & Family Services $13.1 $0.4 $13.5 13%

Basic Needs $1.0 $12.0 $13.0 12%

Adult Addiction Services $0 $10.8 $10.8 10%

Adult Behavioral Health $8.2 $0 $8.2 8%

Senior Services $5.2 $2.5 $7.7 7%

Total $74.9 $30.2 $104.9 Note: The budget data in this table does not include administrative costs or pass-through funds.


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HSD General Fund budget is allocated to the following service categories. Eighty-one percent of General Fund appropriations fall into four service categories: Health Care Services receives the largest appropriation, 31 percent ($19.0 million), followed by Children and Family Services at 22 percent ($13.5 million), Housing and Homeless programs 17 percent ($10.5 million) and Adult Addiction Services at 11 percent ($7.0 million).

HSD Spending by Service Category – General Fund (in millions)

Service Area Contracted Spending

Direct Services Spending Total Spending

Percent of Grand Total Spending

Health Care Services $17.4 $1.6 $19.0 31%

Children and Family Services $13.1 $0.4 $13.5 22%

Housing and Homelessness $9.4 $1.1 $10.5 17%

Adult Addiction Services $0 $7.0 $7.0 11%

Adult Behavioral Health $5.4 $0 $5.4 9%

Basic Needs $0.6 $4.2 $4.8 8%

Senior Services $0.7 $0.3 $1.0 2%

Total $46.6 $14.6 $61.2 Note: The budget data in this table does not include administrative costs or pass-through funds.

More detailed charts displaying funding sources and service categories can be found in the full report.

As part of our review of the services and funding provided countywide, we created a map to identify the location of safety net services throughout Broward County. The map identifies 212 social service providers throughout the county that have a primary mission to provide services to county residents. The service providers included in the map either receive funding through one or more of the major funders discussed above or are funded through private foundations or donations.

When the map is posted, on-line users will be able search by population and category of service to find the location of services; hovering a cursor over a circle displays a pop-up box identifying the name, address and telephone number of the service provider.


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Documenting the Human Services Needs in Broward County. A review of the 25 existing community needs assessments published in the last five years and primary data collected from the Provider Town Hall Meeting, Provider E-Survey, Consumer Focus Groups, and Resident Telephone Survey show that the following are the most significant needs in the county:

• Basic Needs. Our analysis suggests that meeting basic needs (food, rent, cash assistance) is a major issue. Almost half of “211 Broward” calls are for basic needs and about 80 percent go un-referred because no services are available or there are waiting lists for services. According to the provider survey, over half of basic needs providers have waiting lists and according to the telephone survey, when residents were asked what services they need most, nutrition programs, cash assistance, and rent assistance were among the top six needed services. Existing surveys and needs assessments indicate 49.9 percent of households with children are food insecure with moderate to severe hunger; 37 percent of elders report not getting all of the food they need.


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• Access to services. Consumers expressed frustration that multiple applications are required for each program they need and that eligibility requirements are confusing and inconsistent.

• Affordable housing. Affordable housing was mentioned in every focus group with particular note of housing for older adults and seniors, and BARC consumers who were homeless when entering inpatient services and who especially needed help finding housing when discharged. Three-quarters of respondents to the Provider E-Survey listed affordable housing as one of the most common gaps in services. Affordable housing and support services are also a need for teens and young adults transitioning out of foster care and the juvenile justice system.

• Early intervention. Both providers and consumers noted the lack of services available at the “front-end” of the system. Services or one-time interventions needed to prevent a personal or family issue from escalating into a crisis are insufficient. About 40 percent of E-Survey respondents reported that they have waitlists that prevent them from helping families immediately when they apply for assistance. Consumers talked about being ineligible for services because they were not “sick enough” or “poor enough.” Providers discussed struggles to offer services to prevent a crisis when resources were already targeted for on-going interventions. Consumers report sometimes having to wait three months for mental health services; surveys report 50 percent of youth attempting suicide do not receive follow-up mental health services.

• Transition services. Consumers and providers identified service gaps for people transitioning out of mental health treatment facilities and the criminal justice system. Focus group participants expressed the need for more structured support and housing when leaving BARC inpatient services. Providers were particularly concerned that the continuity of care concept could not be fully implemented because services are limited based on income and insurance. Providers also noted the need for secure residential treatment facilities, as well as transitional and permanent supportive housing for individuals who have received treatment and need step-down services in order to re-enter the community.

• Flexible approach to health care. Access to low-cost health care is a top need indicated by residents in the telephone survey; however, participants in the


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telephone survey and focus group participants expressed reluctance to apply for health insurance available through the Affordable Care Act (ACA). Focus group participants said they were concerned that an ACA health plan would limit their options for receiving health care services. Current HSD policies penalize insured residents with high needs by limiting services only to individuals without health insurance. According to providers, particularly behavioral health providers, services are especially needed for families with health insurance, as benefits are often limited or exhausted in efforts to treat family members in need of intensive services. Families may also be unable to afford copays and deductibles. As more county residents are insured through the Affordable Care Act, this may become a more pressing issue. As an example, these barriers prevent insured families from accessing long-term, complex, comprehensive services for individuals with serious mental illness, including children, youth, and families. At least one hospital district has a policy of not providing any services to individuals who qualify for an ACA health plan, regardless of whether the individual continues to pay their premiums or can afford the copays and deductibles.

• Transportation. Transportation remains a constant issue for those struggling to remain self-sufficient while working in low-paying jobs, as well as for those who must travel to sites around the county to receive services. Participants in every consumer focus group noted they are often not able to afford transportation to apply for benefits and take advantage of on-going support services. Older adults in particular in the focus groups expressed difficulty in affording transportation. Three-quarters of E-Survey respondents noted transportation as a major barrier to services.

• System management, integration and collaboration. County residents participating in focus groups believe providers are not well connected and that finding out what services are available is a difficult task. Providers expressed frustration over interactions with the county, especially around contracting, which is seen as rigid and inflexible. They also discussed the many meetings they must attend, many with little real collaboration happening. The county’s role and commitment to collaboration was often questioned – providers are looking for a stronger leadership role from the county.

Strategic Analysis. Based on the analysis of data, insights and opinions gathered throughout our interviews and site visits, we discuss ten areas on which HSD should focus. The recommendations outlined in this section are intended to: 1) increase access


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to basic needs services, 2) reduce duplication of efforts; 3) increase collaboration; 4) improve the continuum of services offered; and 5) improve the quality of services.

1. Streamline Access to Services 2. Develop Single-Stop Service Centers 3. Monitor Impact of the Affordable Care Act and Medicaid Reform 4. Review Direct Services for Efficiencies and Increased Revenue 5. Address Competency Determinations Policy and Procedures 6. Lead Collaboration among Providers and Funders 7. Better Connect Strategic Planning and Budgeting 8. Simplify the RFP Process and Make It More Strategic 9. Strengthen Contract Design and Oversight 10. Continue and Expand the Positive Efforts in HSD Reorganization

Exhibit 1 below is a matrix that displays each recommendation and the need it addresses. Additional detail on findings and recommendations is found in the full report (reference numbers for recommendations identify where in the report a more detailed discussion can be found).


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Recommendations Identified Need

Basic N

eeds

Access

Early Intervention

Transition Services

Health C

are

Transportation

Delivery System

Streamline Access to Services (Section 6.1) Establish an HSD call center using current phone center technology that would allow HSD to track information to better monitoring for quality of services, as well as to manage and plan for resources. (R6.1-1)

Better promote 211 Broward. (R6.1-2) Develop Single Stop Service Centers (Section 6.2)

Rename and establish Family Success Centers as Single Stop Service Centers. (R6.2-1)

Establish all HSD sites as state-designated community partners to assist consumers in applying for Medicaid, TANF, and SNAP (food stamps). (R6.2-2)

Support the continuation and expansion of the One E-Application initiative so that all HSD sites can help consumers identify the range of benefits for which they are eligible. (R6.2-3)

Establish more flexible hours at Single Stop Service Centers and co-locate with community providers where possible to accommodate working individuals and families and those having trouble with transportation. (R6.2-4)

Provide resources to expand public transportation reduced fare options and increase marketing efforts through the non-profit community. (R6.2-5)

Elevate the profile of Veterans Services, move management and oversight to FSAD, and offer veterans’ services in the newly structured Single Stop Service Centers. (R6.2-6)

Refocus Elderly & Veterans Services Division to the Office of Elder Services. (R6.2-7) Conduct a pilot project to assist consumers in applying for federal SSI/D benefits. (R6.2-8)

Monitor Impact of Affordable Care Act (Section 6.3) Consider a policy similar to that of the BBHC (and currently in use by BARC) that allows county funds to be used to meet copays and deductibles and cover services when insurance benefits have been exhausted. (R6.3-1)

Monitor contracted providers, as an integral component of each monitoring visit (or at least quarterly), for the impact of ACA and Medicaid managed care on their revenue and operations, such as changes in the number of Medicaid and ACA clients and changes in Medicaid and ACA revenue. (R6.3-2)

Ensure the new HSD billing unit (see also Recommendation 6.4-1) pursues contracts with the 4 MCOs and 10 ACA exchange health plans for BARC, EDVS, and NJCC. (R6.3-3)

Engage in a marketing campaign to attract Medicaid and ACA enrollees to choose their services. (R6.3-4)


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Basic N

eeds

Access

Early Intervention

Transition Services

Health C

are

Transportation

Delivery System

Review Direct Services for Efficiencies and Increased Revenue (Section 6.4) Create a centralized billing unit within HSD to more aggressively bill Medicaid and third-party insurance for the direct services provided by the Department, including BARC, Elderly Services, and NJJC. (R6.4-1)

Increase the operating efficiencies within BARC to better manage county resources. (R6.4-2) Expedite plans and resolution of issues to move BARC into a new facility. (R6.4-3) Return responsibility for Child Care Licensing and Enforcement to the state of Florida and redirect the county general funds to the priorities for funding identified in this report. (R6.4-4)

Address Competency Decisions Policy and Procedures (Section 6.5) Lead a collaborative effort to develop an effective diversion program in the felony mental health court. (R6.5-1)

Lead Collaboration Among Providers and Funders (Section 6.6) Restructure the Coordinating Council of Broward County (CCB) and the Funders Forum to establish one group to focus on county-wide strategic planning and funding decisions. (R6.6-1)

Establish a Community Engagement Office that gives HSD the needed resources to take on the leadership role to implement collaborative strategic planning and funding efforts. (R6.6-2)

Refocus the Children’s Services Board (CSB) to address the range of services needed for children and youth involved in the juvenile justice system. (R6.6-3) Redefine CSB membership, as needed, to address this new focus, and establish term limits on membership. (R6.6-4) Expand the CSB planning process to include key stakeholders and providers. (R6.6-5)

Better Connect Strategic Planning and Budgeting (Section 6.7) Develop a new HSD Strategic Plan that addresses all categories of service and includes relevant and clear performance measures. (R6.7-1) Establish a policy and procedure to base funding decisions on the new Strategic Plan. (R6.7-2) Reconsider the support of the hospital taxing districts and divert funds to the priorities identified in this report. (R6.7-3) Prioritize funding for the FQHCs over the hospital districts since FQHCs are expected to see increased demand, are a good investment to draw additional Federal funds and have no ability to generate tax revenue. (R6.7-4)

Use primary care funding to support the integration of primary health care and physical health care which is an evidence-based practice. (R6.7-5)


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Basic N

eeds

Access

Early Intervention

Transition Services

Health C

are

Transportation

Delivery System

Simplify RFP Process and Make It More Strategic Improve RFP documents by simplifying RFP instructions, requiring only the information essential to program evaluation and automating the RFP process. (6.8-1) Create a streamlined RFP process for applicants seeking less than $100,000. (R6.8-2) Develop policies to rely on staff expertise and allow more flexibility in the RFP evaluation process, such as eliminating the use of volunteer evaluators, eliminating mandatory applicant interviews, and reducing the number of fatal flaws in the initial review. (R6.8-3)

Focus proposal scoring on outcomes and cost. (R6.8-4) Use the RFP process to leverage interagency collaboration and improve and encourage provider involvement. (R6.8-5)

Strengthen Contract Design, Oversight and Management Increase use of Performance-Based Contracting. (R6.9-1) Adjust staffing levels and responsibilities to meet contract oversight demands. (R6.9-2) Develop a fully-automated database and contract management system. (R6.9-3) Fully centralize contracting staff and reorganize to focus on services. (R6.9-4)

Continue and Expand the Positive Efforts in the HSD Reorganization (Section 6.10) Organize HSD to support new roles and responsibilities (see functions in chart in full report). (R6.10)

Streamline Access to Services (Section 6.1)

Broward County’s wide array of services is a tremendous benefit to citizens but also a complex network of information to navigate. Each division providing direct services within HSD has its own telephone number and handles calls from consumers either for initial information about services available or to contact staff. Residents seeking services can call FSAD’s main number or one of the five Family Success Centers. Callers to the main number are referred to the center nearest to them. Residents also can call the Community Action Agency switchboard to inquire about help with utilities and other services. Seniors and veterans can call the central phone number for the Elderly & Veterans Services. As a result, HSD has eight different telephone numbers that handle almost 19,000 calls per month.


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Findings:

• F6.1-1: Accessing information on services provided by HSD through the Family Success Centers (FSAD) and Elderly & Veterans Services (EVDS) is complicated.

• F6.1-2: HSD receives almost 19,000 calls per month with little information available on the reason for the call, disposition, wait times for callers to talk to someone and other metrics that are important to manage such a large system.

• F6.1-3: 211 Broward is not sufficiently marketed and promoted throughout the county.

Recommendations:

• R6.1-1: Establish an HSD call center using current phone center technology that would allow HSD to track information to better monitor for quality of services, as well as to manage and plan for resources.

• R6.1-2: Better promote 211 Broward.

Develop Single-Stop Service Centers (Section 6.2)

The Family Success Centers can and should be places where individuals and families can get help to remain secure and stable in the community, including help with basic needs and emergency assistance. However, they also need to play a more significant role in helping people to be self-sufficient by accessing the full array of benefits for which they may be eligible, and as an information and referral service for longer-term, more intensive services when needed. To be a true “one-stop,” a system must be designed so that a consumer only has to go to one place or make one phone call to access services. Through one visit to a service center, the consumer should either receive all the information or services needed, or be seamlessly connected with services.

Findings:

• F6.2-1: While Family Success Centers’ stated goal is to be a one-stop shop for residents needing assistance, in practice they are not.


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• F6.2-2: The Broward County Transit (BCT) reduced fare bus pass programs are important but reach a limited number of people who need the assistance.

• F6.2-3: Despite the positive human and economic return on investment, Family Success Centers are not structured to assist residents apply for the full range of benefits for which they may be eligible.

• F6.2-4: Only one Family Success Center (Northwest – Coral Springs) is a state-designated community partner site helping residents apply for Medicaid, TANF, or food stamps. At all other locations, staff refer consumers to other places for assistance in applying for these benefits.

• F6.2-5: HSD is not using the One E-Application, a tool developed through the Department of Children and Families (DCF) that has been available through a pilot project started in March 2013, sufficiently.

Recommendations:

• R6.2-1: Rename and establish Family Success Centers as Single Stop Service Centers.

• R6.2-2: Establish all HSD sites as state-designated community partners to assist consumers in applying for Medicaid, TANF, and SNAP (food stamps).

• R6.2-3: Support the continuation and expansion of the One E-Application initiative so that all HSD sites can help consumers identify the range of benefits for which they are eligible.

• R6.2-4: Establish more flexible hours at Single Stop Service Centers and co-locate with community providers where possible to accommodate working individuals and families and those having trouble with transportation.

• R6.2-5: Provide resources to expand public transportation reduced fare options and increase marketing efforts through the non-profit community.

• R6.2-6: Elevate the profile of Veterans Services, move management and oversight to FSAD, and offer veterans’ services in the newly structured Single Stop Service Centers.


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• R6.2-6: Refocus Elderly & Veterans Services Division to the Office of Elder Services.

• R6.2-7: Conduct a pilot project to assist consumers in applying for federal SSI/D benefits.

Monitor Impact of the Affordable Care Act and Medicaid Reform (Section 6.3)

The implementation of the Affordable Care Act (ACA) and Medicaid managed care are major systems changes that will have an impact on county policy, service delivery, and providers receiving funding from HSD. Since implementation is only now beginning, it will be important for the county to monitor changes in the system with a focus on the impact they will have on both direct and contracted services provided by HSD. While almost 100,000 residents in Broward County are now insured, it is unlikely that any of these individuals have incomes below 100 percent of the poverty level. This group, which was intended to be covered by Medicaid expansion, makes up a significant portion of the individuals served by HSD and other safety net providers in the community. The degree to which the newly insured with remain with the safety net providers they have been seeing is unknown. For those who are newly insured through the ACA, the most significant challenge for HSD is how to address individuals who are unable to pay premiums or copays and deductibles. Copays and deductibles are concepts that are new to people who have been uninsured for significant periods of time. The inability to pay copays and other expenses may result in residents being unable to remain insured once qualified and enrolled in an ACA health plan.

The transition to Medicaid managed care in Florida presents an even more immediate challenge for safety net providers, particularly for direct services provided by HSD. Some safety net providers in the community may also face challenges securing contracts with the four Medicaid Managed Care Organizations (MCOs) in Broward County, and may lose Medicaid clients and revenue as the MCOs choose to provide services in-house or to include other providers in their network.

Findings:

• F6.3-1: The estimated enrollment of approximately 98,378 Broward County residents in ACA health plans during the first open enrollment period is not likely to have a significant impact on the services provided by safety net providers, including the services funded and provided by HSD, because these relatively


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small numbers do not change the insurance status of residents who live under 100 percent of the poverty level and account for a significant portion of the clients seen by the safety net providers in Broward County.

• F6.3-2: FQHCs are facing significant funding challenges.

• F6.3-3: Safety net providers may face a number of capacity issues.

• F6.3-4: Smaller safety net providers will face a number of challenges in collaborating with other safety net providers and contracting with private insurers.

• F.6.3-5: Some changes in the ACA, such as the reduction in disproportionate share funding and the employer mandate, are not expected to have a significant impact, particularly in Florida in the short-term.

• F6.3-6: The most significant challenge for HSD related to ACA is how to support individuals who are insured but are unable to pay their premiums, copays, or deductibles.

• F6.3-7: The transition to Medicaid managed care in Florida presents an immediate challenge to safety net providers, particularly direct services provided by HSD; contracts are required with the Managed Care Organizations in order to become a network provider and continue to serve Medicaid patients and receive Medicaid revenue.

Recommendations:

• R6.3-1: Consider a policy similar to that of the BBHC (and currently in use by BARC) that allows county funds to be used to meet copays and deductibles for cover services when insurance benefits have been exhausted.

• R6.3-2: Monitor contracted providers, as an integral component of each monitoring visit (at least quarterly), for the impact of ACA and Medicaid managed care on their operations, including changes in the number of Medicaid and ACA clients and revenue.

• R6.3-3: Facilitate collaboration among safety net providers to include them in existing and developing integrated networks.


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• R6.3-4: Ensure the new HSD billing unit (see also Recommendation 6.4-4) pursues contracts with the 4 MCOs and the 10 ACA exchange health plans for BARC, EVDS, and NJCCR.

• R6.3-5: Engage in a marketing campaign to attract Medicaid and ACA enrollees to choose HSD services provided through BARC, EVDS and NJCCR.

Review Direct Services for Efficiencies and Increased Revenue (Section 6.4)

HSD operates four direct service programs – Broward Addiction Recovery Center (BARC), Nancy J. Cotterman Center (NJCC), behavioral health services for the elderly through Elderly & Veterans Services (EVSD), and Child Care Licensing and Enforcement (CCLE).

It is unusual for a county government to provide such an extensive array of direct services: nationally about five percent of substance abuse treatment facilities were owned by a local government in 2012 and about 20 percent of children’s advocacy centers are government-based programs. These programs rely significantly on county general funds for their operation and receive little patient revenue.

Each of these services presents a different set of challenges for HSD, especially in light of changes brought about by the transition to the behavioral health Managing Entity, Medicaid managed care, and the Affordable Care Act. HSD administration of CCLE also raises the larger policy question of the county’s responsibility for programs that are within the state purview.

For BARC in particular, the current facility inhibits the ability to operate efficiently, recruit clinical staff, and attract insured individuals who have choices about where to get services. The county should commit to moving BARC into a more modern, functional facility.

Findings:

• F6.4-1: It is unusual for a county government to operate direct services to the extent that Broward County does, particularly facilities like BARC and NJCC.

• F6.4-2: Participating as a provider for new ACA enrollees and Medicaid managed care will be challenging for entities embedded in county government.


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• F6.4-3: HSD does not require BARC or NJCC to use taxpayer funds as the “payer of last resort”.

• F6.4-4: BARC undisputedly plays an important role in the continuum of services for substance abuse treatment in Broward County.

• F6.4-5: BARC has weathered a series of reviews that raised a number of concerns about the administrative operations of the program.

• F6.4-6: As a government entity, BARC has more administrative challenges than non-profit providers of BH services.

• F6.4-7: While BARC has implemented administrative changes to keep detox beds filled (94 percent occupancy in FY 2012), residential treatment beds often go unused.

• F6.4-8: BARC has begun very limited billing of Medicaid, but less than one percent of revenue comes from patients, Medicaid reimbursements, or third party billing.

• F6.4-9: Previous reports as well as some of the stakeholders interviewed expressed concern about the risk to the county associated with operating a medical detoxification facility at BARC.

• F6.4-10: The condition of the facility in which BARC is operating is extremely deficient.

• F6.4-11. Broward County’s child care regulations are not more stringent than the state’s on the measures of importance, such as the quality of care, as determined by national child care oversight organizations. It is not clear what value the county gains by providing this service itself.

Recommendations:

• R6.4-1: Create a centralized billing unit within HSD to contract with and more aggressively bill Medicaid and private insurers for the direct services provided by the Department, including BARC, Elderly Services, and NJJC.


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• R6.4-2: Increase the operating efficiencies within BARC to better manage county resources.

• R6.4-3: Expedite plans and resolution of issues to move BARC into a new facility.

• R6.4-4: Return responsibility for Child Care Licensing and Enforcement to the state of Florida and redirect the county general funds to the priorities for funding identified in this report.

Address Competency Determination Policy and Procedures (Section 6.5)

Community mental health service providers are frustrated by the impact that the number of competency determinations within the felony mental health court has on the system that requires providing services to forensic clients over other individuals. Competency determinations are reported to be inaccurate in many cases and can result in a finding of mental health incompetency for an individual who does not meet clinical definitions of mental illness. Considerable resources for treatment are devoted to forensic clients, leaving significantly fewer resources available for other community residents in need of service.

Findings:

• F6.5-1: The number of incompetent to proceed (ITP) determinations ordered through the felony mental health court is very high compared to other counties in Florida (four times more individuals are determined ITP and released into the community than in Miami-Dade County) and has a significant negative impact on providers of mental health services.

• F6.5.2: The quality of the competency assessments completed for determination of competency has been questioned and the assessments are not considered reliable.

Recommendations:

• R6.5-1: Lead a collaborative effort to develop an effective diversion program in the felony mental health court.


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Lead Collaboration among Providers and Funders (Section 6.6)

Broward County’s mix of public and private service options is extraordinary. Efforts to coordinate funding decisions and collaborate among providers are a cornerstone of the system, and have been for the last decade or more. However, changes in state policy and funding (Children’s Services Council, the Broward Behavioral Health Coalition, and Medicaid Managed Care) have altered the landscape of service delivery and mechanisms to collaborate need to be refocused and revitalized.

The most significant question is: What is the role of the county beyond funding and who should be responsible for how these systems work together? We believe the county Human Services Department is the sole entity that is concerned for every citizen in the county, regardless of what “population” someone falls into for funding purposes, and thus should be the focal point of efforts to bring these major funders together. The recommendations in this section identify changes the HSD can make to organize for this type of role.

Findings:

• F6.6-1: There is no clear understanding about the roles of the Coordinating Council of Broward County and the Funders Forum.

• F6.6-2: Members of these groups characterized HSD’s involvement as minimal.

• F6.6-3: There is a need for a new paradigm that puts the county HSD at the forefront of strategic planning and collaboration across the public and non-profit systems.

• F6.6-4: Since its inception in 1986, ordinances governing the Children’s Services Board have modified its membership to recognize changes in the planning and delivery of children’s services in the county.

• F6.6-5: The Children’s Services Council, with similar but not identical membership, has a charge identical to the CSB – improving the lives of children in the county.

• F6.6-6: In an attempt to reduce duplication, the CSB and CSC separate planning and funding priorities – CSC focuses on prevention; CSB focuses on intervention and treatment.


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Recommendations:

• R6.6-1: Facilitate restructuring of the Coordinating Council of Broward County (CCB) and the Funders Forum to establish one group to focus on county-wide strategic planning and funding decisions.

• R6.6-2: Establish a Community Engagement Office that gives HSD the needed resources to take on the leadership role to implement collaborative strategic planning and funding efforts.

• R6.6-3: Refocus the Children’s Services Board (CSB) to address the range of services needed for children and youth involved in the juvenile justice system.

• R6.6-4: Redefine CSB membership, as needed, to address this new focus, and establish term limits on membership.

• R6.6-5: Expand the CSB planning process to include key stakeholders and providers.

Better Connect Strategic Planning and Budgeting (Section 6.7)

HSD, as a public entity, should have a strategic planning process that includes input from community stakeholders, but that also generates clear and concise goals and objectives that can be used to develop performance measures and inform funding decisions. By more closely connecting spending decisions to strategic planning, HSD can link funding to critical community needs, fund services that are designated priorities, and use the contracting process to build community capacity.

A. Department-wide Strategic Planning

Findings:

• F6.7-1: The HSD Strategic Plan is not a useful planning or assessment tool.

• F6.7-2: Funding decisions within HSD are inconsistently tied to community needs and/or strategic plans.


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Recommendations:

• R6.7-1: Develop a new HSD Strategic Plan that addresses all categories of service and includes relevant and clear performance measures.

• R6.7-2: Base funding decisions on the new Strategic Plan.

B. Evaluate Primary Care Allocation and Spending

Findings:

• F6.7-3. One-third of the General Fund contracts in HSD are used to support two hospital taxing districts whose mission is to provide health care to indigent residents of the county.

• F6.7-4. Contracts with the hospital districts are not based on outcomes; contract amounts have changed very little over the years and the contracts are renewed automatically.

• F6.7-5. Support for the FQHCs results in a higher return on investment and is a more urgent need.

• F6.7-6. The amount of support provided to the local health department is also based on historic spending and the amount is not specified in statute.

• F6.7-7. Very little integration of behavioral health care and primary health care has been achieved in Broward County.

Recommendations:

• R6.7-3: Reconsider the support of the hospital taxing districts and divert funds to the priorities identified in this report.

• R6.7-4: Prioritize funding for the FQHCs over the hospital districts since FQHCs are expected to see increased demand, are a good investment to draw additional Federal funds and have no ability to generate tax revenue.

• R6.7-5: Use primary care funding to support the integration of primary health care and behavioral health care.


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Simplify the RFP Process and Make It More Strategic (Section 6.8)

As a major human services funder, the HSD should ensure that its contract bid solicitation – the Request for Proposal (RFP) process – is clear, does not hinder competition, and is used to strategically leverage public funding. We found a consistent and fair RFP solicitation process that has evolved over time to be very thorough and methodical. However, the resulting RFP format and evaluation process is one that is burdensome for both staff and providers (discouraging some providers from seeking funding), does not allow the department flexibility in decision making, and misses opportunities to leverage the department’s role as funder.

Findings:

• F6.8-1: The current RFP process within HSD is centralized and thorough.

• F6.8-2: HSD’s standard RFP format is complex and burdensome for providers and staff. In particular, small providers are discouraged from seeking HSD funding because of the complexity of the RFP requirements.

• F6.8-3: The volunteer evaluation process is too informal, inefficient, and does not utilize staff expertise.

• F6.8-4: The proposal scoring methodology is inflexible and does not sufficiently weigh the most relevant factors in scoring.

• F6.8-5: HSD does not use the RFP evaluation process to leverage improvements and outcomes in the delivery system.

Recommendations

• R6.8-1: Improve RFP documents by simplifying RFP instructions, requiring only the information essential to program evaluation, and automating the RFP process.

• R6.8-2: Create a streamlined RFP process for applicants seeking less than $100,000.

• R6.8-3: Develop policies to rely on staff expertise and allow more flexibility in the RFP evaluation process, such as eliminating the use of volunteer evaluators,


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eliminating mandatory applicant interviews, and reducing the number of fatal flaws in the initial review.

• R6.8-4: Focus proposal scoring on outcomes and cost.

• R6.8-5: Use the RFP process to leverage interagency collaboration and improve and encourage provider involvement.

Strengthen Contract Design and Oversight (Section 6.9)

Contract design and oversight decisions present an opportunity not just to ensure that taxpayer dollars are being used appropriately, but also to drive improvements in service delivery. Whereas payment in traditional contracts is often per unit of output, performance-based contracting focuses on the quality and outcomes provided and often includes financial incentives to motivate contractors to meet performance goals. In the past 20 years, public sector agencies have been utilizing performance-based contracting more frequently as a way to improve outcomes in a variety of areas.

In addition, HSD contracting is now generally organized around populations rather than type of service. This approach results in inefficiencies as single providers often have multiple contracts to provide similar services to different population groups.

Finally, contract oversight infrastructure – both staffing and technology – are currently at a minimum level. Staff members have little time – and without a contract management database, no tools – to conduct meaningful analyses of provider performance data that could be used to improve service delivery.

Findings

• F6.9-1: The contracting process is not used to drive improvements in provider performance.

• F6.9-2: Contracting functions are not fully consolidated within HSD.

• F6.9-3: HSD has insufficient staffing and technological infrastructure for effective contract oversight.

• F6.9-4: Contract management is inefficient because it is organized by recipient or program, not by type of service.


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Recommendations

• R6.9-1: HSD should increase its use of performance-based contracting, including incentives, to improve outcomes and drive innovation.

• R6.9-2: Fully centralize contracting staff and adjust staffing levels and responsibilities to meet contract oversight demands.

• R6.9-3: Organize contract management around services.

• R6.9-4: Develop a fully automated database and contract management system.

Continue and Expand the Positive Efforts in HSD Reorganization (Section 6.10)

In conducting this community needs assessment, Public Works also was charged with assessing the service delivery system and making recommendations for improvement.

We believe the Broward County Human Services Department (HSD) is the sole entity that is concerned for every citizen in the county, regardless of what “population” someone falls into for funding purposes, and should be the focal point of efforts to bring major funders together.

HSD is organized primarily around populations – children, families, elderly, veterans, homeless, adults with substance abuse problems. While this provides a structure and forum for advocacy and services for each population, it creates a more complex system to address the full range of consumer needs and is prone to overlap and duplication. The silos that now exist will make it difficult for the department to address the recommendations in this report that deal with reducing duplication, increasing collaboration, improving the continuum of care services offered, and improving the quality of services.

Findings:

• F6.10-1: Some direct services currently report directly to the division director for the Community Partnerships Division (CPD) (such as NJCC) while BARC reports directly to the HSD Director; some contracting and monitoring responsibilities are within service divisions rather than CPD.


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• F6.10-2: Divisions in HSD remain in silos based on target populations.

Recommendations:

Next Steps. To take full advantage of this initial community needs assessment report, it will be important for HSD to develop a detailed strategic plan with specific objectives, tasks, responsibilities, and timeline for completion. As in any successful strategic plan, the process for developing such a plan must be inclusive – involving those who must implement the plan.

The plan should include a sufficient level of detail that considers all aspects of the change needed, such as: moving funds to services of higher need; taking an honest look at duplication and overlap of services that may result in changes in funding; reorganizing staff and responsibilities in a way that is respectful of their dedication and builds on their strengths; improving the RFP and contracting procedures to ensure HSD is getting the best innovation and services at the most reasonable price, and engaging key


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stakeholders and the community in changing processes that have been in place for many years in exchange for a new approach that better meets the current needs in Broward County.

This type of comprehensive strategic planning process will require a commitment of resources in order to position HSD for the changes that are taking place now, as well as in the future.

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