Long Term Care Resources Program

Occasional LTC Policy Paper Series
Duke Long Term Care Resources Program Paper No.12
Developing AccessS Services in Mecklenburg County,
North Carolina: THE JUST1CALL EXPERIENCE
Beverly S. Patnaik and Alan K. Geltman

This policy paper features the story of the development and implementation of access services in Mecklenburg County (Charlotte), North Carolina. It comes to you as a part of Duke LTC's Teaching Communities Program which has a goal of sharing progress made in community-wide approaches to long term care among North Carolina communities. In September of 2000, Mecklenburg County launched "Just1Call" a comprehensive, consumer-responsive, technologically-sophisticated system of information and assessment for older adults.

The specific planning and development for Just1Call took about three years under the leadership of the Mecklenburg County Department of Social Services. But, as in many communities, the vision of having a comprehensive system that would connect older adults and their caregivers to needed services goes back well beyond these three years. Direct antecedents can be traced to the late 1980's. Mecklenburg's early experience with access systems will undoubtedly resonate with other communities, inside and outside of North Carolina, while its more recent experience with making the developmental and technical leaps to implement a system will provide useful comparative information for communities on similar paths.

Readers are encouraged to note that Mecklenburg County started with designing a consumer-responsive system and then sought technical assistance on how to automate the conceptual design.

Lead author, Beverly S. Patnaik, first as executive director of the Charlotte-Mecklenburg Council on Aging (1980 to 1985) and then as assistant director of the Services for Adults Division of the Mecklenburg DSS (1990 to 2000) lived the detail of the development of access services in Mecklenburg County. A recent addition to the staff of Duke LTC, she was educated at Central Wesleyan College and North Texas State University, where she received a master's of gerontology. Co-author Alan Geltman, a social worker with over 25 years experience, coordinates Just1Call for the Mecklenburg County DSS. The authors want to highlight the contributions of the many participants in the Just1Call development process, and especially thank Jake Jacobsen, Director of the Mecklenburg County DSS, for his leadership and encouragement during this process.

DEVELOPING ACCESS SERVICES IN MECKLENBURG COUNTY, NORTH CAROLINA: THE JUST1CALL EXPERIENCE

Implementing a community's vision for developing an effective, accessible system of information and assessment takes time, resources, leadership and commitment. This paper is the story of Just1Call, a service operating in Mecklenburg County, North Carolina that provides a universal portal of access to services for its older and disabled adults, their families and professional caregivers. This paper also describes the impact of policy decisions on implementation. The process of how Just1Call went from a vision to a reality through planning and implementation is described.

County Leadership Recognized the Fragmentation of Aging Services

As early as the mid-1980s, members of the aging services community recognized that a fragmented service delivery system existed in Mecklenburg County as in most communities. It was difficult for older adults, their families and other providers to find out what services were available, where, and in what quantity. In response, in 1987, the North Carolina General Assembly funded a small number of demonstration projects in the state to create effective ways for older adults to locate and access services in their communities. Mecklenburg County was selected as one of the sites and established AGELINE, an information and referral service, with a case management component, to handle the more complex cases that came to AGELINE. These services were created under the auspices of the Charlotte-Mecklenburg Council on Aging, and the services were provided by the United Way and the Charlotte-Mecklenburg Senior Center. While the services met a need in the community, the funding for the demonstration projects from the state was not ongoing. AGELINE continued with funding from United Way, but the case management component did not. AGELINE was not marketed widely and as time passed, very few older adults and service providers knew of its existence.

In the early 1990's, the Home and Community Care Block Grant (HCCBG) in North Carolina was mandated, which block granted Older Americans Act and similar state funds to counties. The HCCBG advisory committee in Mecklenburg County decided that meeting only about the funding issues once a year was not enough to know about the needs, met and unmet, in the community. The 60+ members of the HCCBG Advisory Committee formed the nucleus of the Charlotte-Mecklenburg Aging Coalition (C-MAC), a group whose purpose was to facilitate inter-agency cooperation, identify critical issues and promote response strategies. One of the immediate goals of C-MAC was to identify unmet needs of the elderly in Mecklenburg County. Brown bag lunches were held to gather ideas from community leaders, consumers, providers and advocates about gaps in services and how to fill those gaps. Many ideas were offered and several gaps were identified as top priority to be tackled. A recurring theme continued to be how older adults and their families became aware of and connected with services.

Mutual interests were combined with mutual agreements to find solutions to consumers' difficulties in finding answers to their questions about services easily.

C-MAC members convened an Aging Summit in December 1996. Prior to the Summit, a random telephone survey was conducted to gather current community information to assist in identifying options and making decisions during the meeting. One of the findings from the survey was that 35% of the elderly and their caregivers did not know where to call for information. At this daylong community summit, attended by key stakeholders and consumers, information was presented about needs identified in the community, and discussions led to a consensus about highest priority needs in the community to be addressed. Creating a universal point of access for service information, a need that had also been identified in 1987, was re-confirmed.

Three work groups were organized around specifics of how to accomplish this task: Development of the concept of making services more accessible, case management of complex cases, and funding of the service. Recognizing the complexity of the task, the more than 40 people who participated as members of the work groups reported their progress at the monthly meetings of C-MAC. The dedication of these work groups laid the foundation for the successful implementation of what was to become in 2000 Just1Call. The initial working name for this service was Single Method of Access (SMOA).

There were many ups and downs as this process went forward over the next four years. None of the grants applied for received funding and everyone realized that with no resources, this process would not go forward. No agency in the community could underwrite the project with current staff and resources. At this critical time, the Mecklenburg County Department of Social Services, under the leadership of Richard W. (Jake) Jacobsen, Jr., Director, stepped up to the plate and requested funds from the Board of County Commissioners to begin working in earnest on making this universal method of access a reality. In 1997 the Mecklenburg County Commissioners approved the first funds and have continued to increase the resources available to the project each year. The emerging consensus to proceed with single method of access now had a continuous funding stream.

With resources in hand, the Mecklenburg County Department of Social Services selected Alan Geltman, a social worker with 24 years experience, to provide the leadership needed to implement what was to become Just1Call. His in-depth knowledge of community resources and systems, as well as his enthusiasm for effective service provision, were key to his ability to provide the necessary leadership in this process.

In 1998, the second phase of developing this community-wide approach began. Using the information from the three C-MAC work groups, a community Design Team, from both public and private organizations, was formed. The members, broadly representative of key participants in services for older adults, included staff from the two hospital systems, private home health care agencies, the Charlotte-Mecklenburg Senior Center, the Charlotte-Mecklenburg Council on Aging, the Public Health Department, the United Way of Central Carolinas, Region F Area Agency on Aging, and AGELINE, as well as older adults. The purpose of the Design Team was to specify a conceptual framework for this service, to proceed to strategic decisions about effective access service provision and finally to develop a business design to implement this universal access to services. Alan Geltman provided the leadership for the team, which met weekly for ten months.

One of the primary responsibilities of the Design Team was to reach out to the community during this phase and the first act of its members was to listen to both service consumers and providers. This was accomplished by convening focus groups of older adults, their families and service providers in several venues in the community; by keeping the members of C-MAC involved every step of the way; and by listening to, as well as talking with, service providers both individually and in groups.

Findings from the focus groups were critical to the design of the information service:

These factors were considered crucial and were taken into account by the Design Team.

Members of C-MAC who were not on the Design Team also had input into the process. The issues of impartiality, inclusion, and presentation of alternative agency services were addressed early on by members of C-MAC. Members of the aging service provider community felt strongly that the information and referral service, as well as the case management component, should offer choices to all callers. It was particularly important that DSS assure the other service providers that callers would not be automatically funneled to DSS services. The fact that the Design Team was composed of volunteers that represented a cross-section of the aging service providers, from both public and private organizations, was therefore important. The members committed to leave special pleading for their organizations' interests at the door and to focus on meeting the needs of the consumers for whom this access service was being designed. Use of ground rules for inter-organizational planning, as developed by Roger Schwarz¹ was adopted. These ground rules facilitated communications throughout the process of creating what became Just1Call.

¹ Schwarz, Roger M. (1994) The Skilled Facilitator: Practical Wisdom for Developing Effective Groups. San Francisco, CA: Josey-Bass, Inc.

The conceptual design phase focused on developing formal statements of the vision, mission, guiding principles, goals, and objectives of this system or approach. Additionally, as part of the conceptual design phase, more than twenty objectives and eighty-eight strategies were developed which provided detail and depth for future work. The Design Team defined and agreed upon the following:
VISION: Just1Call will be recognized as a source of complete, accurate and friendly assistance to address the life concerns of aging and disabled people.
MISSION: Just1Call will provide a system that enables an older or disabled adult, their family or caregivers to make one contact to obtain information, assessment of need and access to care. To enhance quality of life, Just1Call includes follow-up, advocacy and problem resolution.

The vision, mission, guiding principles, goals, objectives and strategies were used as "guideposts" throughout the design process and kept the team on track as they conceptualized the service. The detailed exercise of developing these guideposts proved to be time well spent as the project was implemented. Having these well-defined guideposts reduced unnecessary delays during implementation of the concept.

The next step in the development was the strategic design phase. Using the eighty-eight strategies, the Design Team employed a flow charting technique to facilitate the process. Allyson Berbiglia, Consultation, Education, and Training Specialist with Mecklenburg County, led the Design Team through all the steps and decision points from when the consumer called to the point at which the consumer received the service needed. This rigorous process took about two months. Flow charting the process generated almost as many questions as it answered. For example, the original concept was to have an "information specialist" initially answer the call and then hand it off to a social worker if the request from the consumer was a complex one. That concept nullified the goal of having the consumer only talk to one person. After much discussion and consultation with county human resources, a decision was made to hire only social workers so that callers would talk to one individual.

The decision to have Just1Call's calls answered by social workers was significant. It recognized the value of having trained professionals who can listen with a "third ear" and make an informed judgment call as to whether to probe for more information from a caller or take the initial request at face value. Experienced social workers have the ability to delve into deeper issues when they sense the caller is struggling to raise difficult topics.

After the conceptual and strategic phases came the business design phase. Just1Call wanted a fresh, creative look at how to design a system and automate it. In consultation with Mecklenburg County Information Technology staff, an outside consultant with no human services background, but with extensive computer and telecommunication experience, was hired to assist in this design phase. The consulting firm, providing the technical architecture for this access service, conducted a business analysis. This analysis took five months and focused on three areas: Project initiation, business requirements and business design. These components of a systems development life cycle methodology assisted in answering the important questions of how the proposed system would resolve problems of the existing fragmented system; how specific functions and flow of the new system would work; and how to evaluate options such as automation platforms, connectivity and recommendations for implementation options.

For example, after a great deal of research, which included talking with and visiting access services across the country and exploring the availability of existing automation systems that met the needs of the Charlotte-Mecklenburg community, the decision was made to design and program a screening tool. The available screening software systems did not meet the needs of this system, and the cost of adapting current software was as much as the cost of designing a "custom" system.

A vital lesson learned during this technical design phase was that the scope of the project was greater than originally conceived. To collapse more than 20 objectives and 80+ strategies into a single method of access was a challenging undertaking. Keeping in mind the goals to reduce inappropriate referrals, to save the consumer time, and to close the loop between the consumer, the service provider and Just1Call staff, the decision was made to design a screening tool, a basic building block of a service information system, that could be used by social workers talking with consumers on the telephone. Input on the design was obtained from many sources, including experts in the information and assistance field, programmers, and users. The screening tool was designed with efficient workflow in mind, as well as the ability to archive and retrieve information quickly.

It was during this phase that the Design Team's role changed from one of weekly decision-making meetings, to that of receiving information via print that was mostly technical in nature. The Design Team's almost yearlong activity was now being translated into an automated system. The Design Team continued to be needed in an advisory capacity and the transition went from weekly meetings to communication primarily by email. A member of the team was on the interviewing team for the business analyst and the team continued to meet sporadically during this phase. While many issues had to be monitored, the need to keep the Design Team active on a weekly basis diminished. Updates on the process and progress continued to be provided at the monthly meetings of C-MAC. The implementation phase was dominated by the programming of the screening instrument, the marketing of the service and the launch of Just1Call.

While the business analysis was being completed, other vital components were simultaneously being developed. One involved the critical decision of how to handle confidentiality issues. Just1Call employs the standards published by the Association of Information & Referral Systems (AIRS-www.airs.org) and the established policy of the Mecklenburg County Department of Social Services. The consumer gives explicit verbal permission for information to be disclosed to any other person or agency. Just1Call staff either has a three-way conversation with the consumer and service provider, or they ask for verbal consent to share information. This verbal consent is indicated on the screening tool so the Just1Call social worker knows he/she has permission to share certain information with service providers.

As Just1Call formalizes its assessment component, an enhanced automated consent to release information form will be developed to share vital information (such as medical information) with service providers. This will be a time-limited and data-specific consent form.

Operational protocols were developed based on discussions and decisions made by the Design Team during the previous phase. The protocols addressed the following questions:

The answers to these questions were specified in detail in the protocol manuals developed by the Just1Call staff.

Staff from the Better Business Bureau of Southern Piedmont, the Charlotte Chamber of Commerce, MEDIC (the Mecklenburg County EMS provider), Area Mental Health Authority, the United Way of Central Carolinas, emergency services division of the Center for Behavioral Health, and a crisis intervention specialist assisted in developing these protocols.

After the business analysis was completed and a screening tool prototype developed, the project moved to the implementation phase. This phase took about nine months and involved both county and community commitments. The Board of County Commissioners, the County Manager, and the Director of Mecklenburg County Department of Social Services, were kept informed about this project and provided continued leadership and support during the implementation phase. On the county's side the decision was made to have county information technology (IT) staff program the screening tool, rather than hire outside consultants. An important factor in this decision was the advantage of county IT staff being able to support the software comprehensively and make the inevitable changes as time passed. Experience with other county automation projects reinforced this decision.

Early on an automated screening tool was recognized as an essential building block of the Just1Call Service. The tool was designed to collect information as it is given to the social worker during an initial telephone call. No matter what subject the consumer brings up, the social worker can immediately bring up that topic on the computer screen. Not only is the screen easy on the eyes, but it is also easy to manipulate. The screening tool is multi-dimensional and collects the following information when someone calls and requests more than just a telephone number for a service:

The Just1Call screening tool has full report-generating capabilities, as does the telephone system selected for this service. Reports can be requested that document consumer demographics, referrals made, unmet needs, etc. Visual Basic was selected as the language for programming because of its flexibility and a SQL server is used. The screening tool is a Windows-based application. (Additional note: As this issue goes to press, the Just1Call screening tool is mid-way through its first year of full implementation during which it is being fine-tuned based on experience.)

Just1Call partnered with the United Way of Central Carolinas Information and Referral staff to develop a method to share data from their database. Because of the large proportion of long term care that is provided by the for-profit sector, the decision was made to include for-profit service providers in the Just1Call data base, a departure from the United Way's mode of doing business. Working with the United Way's staff, Just1Call staff developed inclusion/exclusion criteria for for-profit agencies. The following criteria were designed to meet aging and disabled consumers health/wellness needs by service providers:

More than 500 specific programs for the aging and disabled were identified and contacted to provide accurate information about their services. Additional services were added to the United Way database and a method for maintaining an accurate, up-to-date service provider listing was developed. A decision was also made to charge no fees for being listed in the database. Any aging or disabled service provider who meets the inclusion/exclusion criteria can be listed. All these services are listed in a commercially available software product used widely by United Ways and aging agencies in North Carolina.

Because the marketing of this service was an essential component of Just1Call, $100,000 was included in the start-up budget for professional marketing. Before the bids were let, advice was solicited from the county's Public Service and Information Division, service providers, the Design Team and experienced marketing firms. Bids were requested and the contract was awarded to a marketing firm in Charlotte, NC, with much experience in the human service arena.

To use a professional marketing firm has proven to be an important decision. The tasks assigned to the firm included researching and analyzing the best way to get out the message about Just1Call; proposing a name, logo and tag lines; designing all printed material; handling advertising and public relations; insuring a consistent "look and feel" of the service; and designing a web page that would be consumer friendly. Their techniques included several strategic planning sessions with DSS and other community agency staff. A research firm subcontracted by the marketing firm conducted a second round of focus groups that included the elderly and their caregivers, leaders in the African-American, Hispanic and Asian communities, and service providers.

The Just1Call name, its logo, and tag line (One Call. One Source. Wonderful!) were all tested with various focus groups. The marketing firm completed letterhead design and brochure development (in both English and Spanish). The local telephone number was chosen for ease in remembering: 704-432-1111. There is also a toll free number: 1-877-889-0323. The design of the web page was done in collaboration with the county's IT department and the web page was translated into Spanish, as well. The web page can be viewed at www.Just1Call.org. The web page offers access to the provider database, as well as the ability of the user to communicate with the Just1Call staff by email.

Marketing of Just1Call has included articles in the local newspapers, contacts with service providers, houses of worship and community agencies; and distribution of brochures. In November and December 2000, advertisements were placed in the major local newspapers, including those serving the minority and international communities. Radio and television ads were aired during this same period. The underwriting for these advertisements is being covered by private sponsors. This is an unprecedented involvement of private enterprise in the marketing of this human service effort.

The growing multi-cultural and international community in Mecklenburg County raised an important concern: How could Just1Call be equipped to serve the aging and disabled population in the international community? Several avenues were taken to assure that Just1Call would be a service that meets the needs of non-English speaking residents of the county. Many discussions were held with members of the international community by the Just1Call project coordinator. A list of cultural as well as language barriers that Just1Call would need to overcome was compiled. Meetings were held with leaders in the Hispanic, Asian, and other non-English speaking communities to talk about the need for this service. The project coordinator met with staff at International House, an organization in the community that serves as a clearinghouse for needs and advocates for a better understanding of the cultures of people from other countries. A service from AT&T called Language Line was installed on the telephones for the Just1Call staff. Any language spoken can be translated using this service. A $25,000 grant from the Older Adult Wellness Council of the United Way of Central Carolinas was awarded to develop marketing strategies specifically targeted to the international community.

One of the striking facts which emerged from the focus groups conducted as a part of the marketing process was the reluctance of minority residents to utilize services provided by the government. Therefore, a decision was made to de-emphasize that DSS was the agency providing Just1Call and to market it as a stand-alone entity. Across the board the focus groups verified that access to information and services was a hardship. Often culture, more than language, is the key barrier.

Having a quality assurance component as well as outcome measures has always been fundamental to the design of Just1Call. Harry Hatry in his book Performance Measurement: Getting Results¹ defines outcome measurement as "measurement on a regular basis of the results and efficiency of services." Outcome measures assist staff in providing better services more efficiently, help set service target levels, guide program adjustments to improve services, and encourage new service approaches. Outcome measures also inform staff about "how we are doing" to motivate their efforts, allow supervisors to use measurement results as motivational tools, and give managers tools to make operational resource allocation decisions. Another plus for using outcome measures is to develop benchmark data to compare to previous time periods. The outcome measures developed for Just1Call use the six components of the Hatry model: Inputs, Activities, Outputs, Outcomes (both intermediate and end), Indicators, and Unit-cost Ratios.

In human service programs, the key outcome question is: What differences did this service make in the quality of life of the consumer? There are six outcome measures that Just1Call is using during this first year of operation. Each measure reflects the above components. For example, one measure examines the efficiency of the Just1Call service. Skilled social work staff, computer and communication technology, and the financial resources are inputs; activities are the time social workers are budgeted to answer phone calls and make home visits to consumers; outputs are the number of calls answered and the number of web hits; outcomes specified include that 75% of the time consumers will be linked to services in one telephone call or home visit and that consumers receive accurate provider information; and indicators are obtained on the automated quality assurance survey.

Building on the framework discussed above, Just1Call has developed a quality assurance survey that will be conducted by Just1Call staff on a randomly selected number of callers on a predetermined basis. The purpose of the survey is to find out if consumers felt Just1Call met their needs. The survey is short (takes less than five minutes) and the responses are elicited on a scale of 1-5, with 1 being extremely satisfied and 5 being extremely dissatisfied with the service. The consumers are assured that the results are kept confidential. It is planned that about 20% of the consumers will be surveyed. Having the staff who provides the service also conduct the survey raises some questions about the validity of the responses given. At this time in the project the decision was made to conduct the survey in this manner in order to have some initial data for analysis. Resources currently available do not allow for an external evaluator to conduct the survey. There is also a survey on the website for web consumers to use.

Just1Call was officially launched on September 6, 2000, almost 2 years after the planning began. Initial evidence indicates the service averages about 40 calls per day. More than 40% are requesting information only; another 54% need referrals and about 6% have requests that the community cannot meet. Less than 10% of the calls need a home visit from the social worker to ascertain the needs of the caller. As of January 15, 2001, Just1Call staff have received 2400 calls and have made 6800 referrals to more than 500 agencies. The web site receives 40-50 visits every day. Thirty-three percent of the callers are <60 years of age.

Initial staffing of Just1Call consists of a project coordinator whose primary responsibilities are to see that the service continues to meet the needs of the community; a social work supervisor who takes care of the day-to-day running of the service; seven social workers who answer the telephone calls and who also provide the assessments if needed; and one office assistant who keeps the data base updated, posts new information on the community bulletin board section of the web page, and handles other office duties. Social work staff was hired in April-May, 2000. Even though all were experienced social workers, extensive training on community services was provided. The Just1Call staff made site visits to community agencies, strengthened their assessment skills by conducting home visits to DSS clients, and field-tested the new computer and telecommunications systems.

The amount of resources a start-up program has at its disposal is one critical factor contributing to its success. The initial budget for Just1Call was almost $300,000. More than two-thirds of those funds were spent on software development and the rest on automation hardware, telecommunications equipment and personnel. The first annual operating budget is almost $830,000, with $375,000 for personnel, $91,000 for marketing, about $200,00 for continuing software development, and the rest for operating expenses.

What is the future of Just1Call? Continuing to work with community agencies and groups to get the word out about Just1Call is at the top of the list. Forming a community advisory group to insure that Just1Call continues to be responsive to the needs of the community is in the plans for year two. Also solidifying the relationships between Just1Call and the service providers is a key element to be pursued. Extending service hours from 8-5 to 8-8 on weekdays and being open on Saturdays from 8-2 is another goal. Expanded hours are based on requests from consumers. Having Just1Call social workers stationed in other community service organizations (hospitals and senior centers) is being discussed. Adding significant web links to the web site and having Just1Call linked to other web sites is a priority. Continuing to add service providers in a timely manner will strengthen the use of the web. The connectivity of data to service providers by way of a high-tech application of email is a topic of exploration. Integration of this service with other communities is being discussed. With that discussion comes additional issues surrounding confidentiality, including ways to create privacy "firewalls" so electronic sharing of information can be accomplished. Does the service need to be privatized? How far should Just1Call go in automating an assessment tool? Some of the above issues are operational in nature and decisions about them will be made by DSS. Others involve the community and its perception of needs and will be discussed and developed by the community advisory group.

There are number of work groups in North Carolina also looking at many of these issues and Just1Call has cooperated with efforts. Hopefully, some of the decisions at the state level will be in time to be useful to Just1Call, but in the meantime, Just1Call will continue to proceed on its implementation plan.

In summary Just1Call is a service that responded to an urgent community need in Mecklenburg County. The process described in this article demonstrates the success of a public-private collaboration whose goal was to provide a much-needed service in the community. The leadership provided by the Mecklenburg Board of County Commissioners and the Department of Social Services was essential. Without their support and resources Just1Call would not be the reality it is today. The investment of more than two years of planning and the initial cost of almost $300,000 will be worthwhile if an effective universal access to aging and disabled services has been achieved.