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Building a Coordinated System of Care: A Cross-Agency Response for Effective Services


One of the most exciting and innovative things going on in the City of Philadelphia social service world in the first 10 years of this century was the development and implementation of a coordinated system of care across social service agencies and providers. For several years, the term “No Wrong Door” was an idea that was discussed in many circles and attempted by a few. In 2005, the newly hired director for the Division of Social Services stepped in, emboldened to turn it into reality.

The Division of Social Services within the Managing Director’s office, then under Julia Danzy, was embarking on a no-holds-barred endeavor to develop and launch a system of care in social services that was new and rare in social service practice and very definitely different in the City of Brotherly Love. I was recruited to help make that happen. We called this coordinated system the Division of Social Services Cross Agency Response for Effective Services (DSS CARES).

This system implied changing the way we do business from the bottom up. If implemented fully, the case manager at the point of service would use a comprehensive interface that would provide relevant information on the care history in different social service agencies of the client and/or family, where appropriate and with client consent. The system offered the potential to address holes in the safety-net, and to coordinate care among services for members of the family.

It would be the first time that managers would be able to use centralized data to manage performance and cases across the different departments. We knew that cases in the Behavioral Health system were likely to also be a part of the Department of Human Services, the Office of Supportive Housing and maybe even the Philadelphia Prison System. We wondered, however, if the Pareto principle applied to these circumstances, such that 20 percent of the cases were taking up 80 percent of the total cost of services. According to a state of the City report by the Department of Human Services, we knew that a full 35 percent of children under the age of 18 were living below the poverty level in Philadelphia. The dropout rate in our public high schools was hovering around 50 percent. We knew that many of these children and families were already receiving city-managed social services.

I had read and was moved by Peter Senge’s classic The Fifth Discipline: The Art and Practice of a Learning Organization. In it, he wrote that a learning organization is one whose people are continually expanding their capacity to create their future. With a fully implemented system in DSS CARES, I felt we had the opportunity to fundamentally change the way we deliver services, get data that provide a client-based view, and maybe change these families’ and our own future. Management could see aggregated data about families for the first time, within and outside of the agency silos, and be able to thoroughly appraise services provided, including frequency and quantity over years. This could encourage measurable, immediately responsive programmatic change.

DSS CARES had 4 stages. It was in this combination that the innovation lay, and also the burden. We knew it was ambitious to attempt to introduce change on several fronts at the same time. The 4 components of DSS CARES were:

  1. Data architecture that centralized the data;
  2. Legal and confidentiality compliance for this new system;
  3. Training frontline staff, case managers and providers on changes in the way we tracked and coordinated the provision of services at the point of service; and
  4. A comprehensive data management and performance evaluation framework to capture the collaborations and provide accountability.

The data architecture allowed for the flow of data from point of service to the case management information across the departments. These were gathered in one repository we called the data warehouse. This was a searchable database that could generate information and respond to queries within determined protocols of security.

Internally, we had to assure that levels of confidentiality were kept that would support the service and keep the information safe. Further, the social work ethic of informed consent on the part of the client to share data across systems was a significant issue. We had to consider different levels of access to data and think about security and convince the client family why it is to their benefit to allow for viewing of their information.

Taking on cross-systems training of case managers, commissioners and social work supervisors was immense in its implications. The system and software designers, advised by user groups, were designing a common interface that would be easy to navigate and have common definitions that all case managers understood. In theory, once we had a common interface approach, service providers, case managers and social workers would be able to work with clients to coordinate service. Case managers were to adjust to a whole new way of seeing and serving clients/families.

We needed a cross-systems evaluation model that would allow for measurement of the impact we sought to make, and found one in the Results Based Accountability framework by Mark Friedman. It was in this group that I could see the wheels of coordinated services begin to turn. We needed to find common elements and significant outcomes across systems that would demonstrate community impact.

Was it possible to operate on all of these fronts at the same time? Maybe?

We could see the potential over and over again when we gathered managers from these different agencies in one room. In our performance measures and Results Based Accountability meetings there was one discussion that I still remember very clearly. The discharge unit at the Prisons had just finished a presentation about their process for discharging prisoners. The manager in the Office of Supportive Services lit up after their presentation and said to the discharge manager of Philadelphia Prisons, “It looks like to me like we should set up shop somewhere in the Prisons to catch them when they are discharged.” 

For me, this was the beginning of cross-systems thinking. This was an early indicator that our managers were beginning to come out of their silos in a very tangible way to see ways to share resources to effectively serve as well as improve outcomes. We were becoming a learning organization. We were expanding the City’s capacity to create our future and the future of the City’s residents by changing from our systems view to a client view.

To change a system of this size, there were a few challenges, to be sure. What did I learn? I learned that large systems are difficult to change and even identifying bright lights in the system and people ready for change cannot offset the call for an incremental process.  

I learned how powerful it was to have managers and users from the dominant social service agencies in one room and the palpable shift in thinking that happens when they begin to see common interests. Managers were grasping the tools that could help us demonstrate the gap between where we want to be and where we are. And that was the most exciting learning of all. 

DSS CARES was an ambitious effort. We understood the burden. Did we shoot for the stars? Yes. Was it fully implemented? Maybe, not fully. Did it fall short? No. If nothing else, CARES left behind the foundation for the next generation’s substantive conversation around collaboration and coordination across social service and other agencies that provide services for these same families. It left behind a model and infrastructure for sharing data across agencies. 

I close very hopeful. There are initiatives all over the city that echo DSS CARES. The Philadelphia District Attorney’s PreEntry Program is seeking to collaborate and coordinate across criminal justice and other agencies to develop a client-based system that responds to issues of drug addiction, mental illness and illiteracy. Philly Rising, out of the Managing Director’s Office, empowers the local leadership of many of our distressed communities to get them resources that will move them to a trajectory of success. The Mayor’s Sustainability Office is running innovative initiatives and collaborations across agencies, within and outside of City government.

Mario Morino reminds us in his book Leap of Reason: Managing to Outcomes in an Era of Scarcity (2011) that the economy has taken a major hit. As we see cuts to our social service budgets, we will also ironically see increased demand for these same services. This will require agencies, and maybe even cities, to reinvent themselves. These cross-agency initiatives show we are doing this already. DSS CARES was only the beginning.

Annabella Roig, MS, MPH is the Former Assistant Managing Director, Division of Social Services for the City of Philadelphia, and has also served the Philadelphia Department of Public Health, Department of City Planning and Philadelphia Housing Authority. Annabella is currently with Nueva Esperanza, serving in their National Programs division. 


Senge, P.M. (1990). The Fifth Discipline: The Art and Practice of The Learning Organization. New York: Doubleday/Currency.

Friedman, M. (2005). When Trying Hard is Not Good Enough: How to Produce Measurable Improvements for Customers and Communities. Victoria, BC: Trafford Publishing.

Morino, M. (2011). Leap of Reason: Managing to Outcomes in an Era of Scarcity. Washington, DC: Venture Philanthropy Partners.