The Inter-agency Services Collaboration Project By Joan Roberts and Pauline O’Connor Table of Contents: 1 INTRODUCTION AND OVERVIEW REPORT BYJOAN ROBERTS AND PAULINE O’CONNOR 21 SERVICE DELIVERYCOLLABORATION IN NONPROFIT HEALTH AND COMMUNITYSERVICES: What does Government Want? BYROB HOWARTH 32 DOES COLLABORATIVE SERVICE DELIVERYIMPROVE CLIENT AND ORGANIZATION OUTCOMES? AReview of the Evidence on NPO Collaborations in Health and Social Services BYMARIE BOUTILLIER, PAULINE O’CONNOR, TOM ZYZIS, JOAN ROBERTS AND KRISTABANASIAK 67 COLLABORATION WITHIN BUSINESS AND GOVERNMENT: What are the Objectives, and what is achieved? AScan of the Evidence BYTOM ZYSIS 89 THE STATE OF SERVICE DELIVERYCOLLABORATION IN THE TORONTO NPO SECTOR: AKey Informant Study BYHEATHER GRAHAM 110 POLICYSUPPORTS TO THE NPO SECTOR: AQuick Scan of Other Jurisdictions BYKRISTABANASIAK 124 THE EAST SCARBOROUGH STOREFRONT PROJECT: Asuccessful inter-organizational service collaboration BYBRENDAROCHE AND JOAN ROBERTS 163 REVISIONING KIN: Aservice delivery system visioning project BYJOAN ROBERTS APPENDICES 218 GLOSSARY 224 REFERENCE GROUPMEMBERS 225 PROCEEDINGS OF THE ROUNDTABLE REPORT Inter-Agency Service Collaboration in the NPO Sector By Joan Roberts and Pauline O’Connor Inter-Agency Service Collaboration in the NPO Sector Introduction Collaboration has become a major focus of attention and action in business and government over the last several years. The number of collaboration initiatives within the private and public sectors, as well as between those sectors, has increased significantly over the last decade. Government’s, and to a smaller extent, the corporate sector’s, interest in collaboration within and with the NPO sector, has also increased. In Canada, this interest has been reflected at the federal level most recently with policy statements such as the 2001 Accord Between the Government of Canada and the Voluntary Sectorand the 2002 Code of Good Practice on Funding,which outline respective roles and responsibilities and shared values to guide collaboration between Ottawa and the NPO sector.1 The discussions around collaboration within and among the public, private and NPO sectors sometimes suggest collaboration as a “magic bullet” for solving increasingly complex social and economic problems and societal structural challenges. Within the NPO sector, collaboration is hardly a new strategy or idea. The current interest in collaboration as a society-wide strategy, however, brings the issue of NPO collaboration into the orbit of these broader policy discussions, and raises new questions and expectations for the sector. But what does collaboration mean for the NPO service sector? Is it a useful strategy in the sector? What does it achieve? Who supports it and why? How, when, and with whom should NPO organizations collaborate? Should their collaborations be driven by the same goals and strategies as drive government and business collaboration? One of the ways in which the Wellesley Institute advances urban health is through building NPO sector capacity to provide sustainable, effective services that improve outcomes for disadvantaged populations and communities. The current attention and action on collaboration suggests that collaboration is a potentially powerful strategy to build the capacity of NPO services in ways that improve outcomes. The Wellesley Institute initiated this project in collaboration with other Toronto NPO capacity builders as the first in a series of projects to investigate collaboration’s potential to enhance NPO capacity and effectiveness in Toronto. SCOPE AND DEFINITIONS What is “collaboration”? Broadly speaking, collaboration refers to individuals or organizations working together to achieve a common purpose. (See Appendix Afor a glossary of terms used in discussing NPO collaboration.) Collaborations can involve varying degrees of sharing of authority, resources and information. But they fall short of full amalgamation or union of the participants into a new entity. 1These policy statements emerged from the work of the Voluntary Sector Initiative, which in turn resulted from the 1999 Voluntary Sector Roundtable or “Broadbent Panel’s” report, “Building on Strength: Improving Governance and Accountability in Canada’s Voluntary Sector” (VSR). WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 2 Inter-Agency Service Collaboration in the NPO Sector The NPO sector encompasses many different types of organizations providing many different types of services. Moreover, NPO organizations collaborate – with each other and with other sectors – in widely different ways. They may collaborate to advocate and inform policy-making and system change; to coordinate and plan services across geographical regions and service areas; or to plan and deliver direct services to clients. NPOs across a whole sector, such as mental health providers, may collaborate together. Or the collaboration may involve a few individual agencies whose staff know each other and come together to exploit specific opportunities to improve services or influence policy. Often, individual organizations are collaborating in many ways, with many different groups of organizations, at the same time. This first project set out to examine one slice of NPO collaborative activity -- collaborations among NPO agencies that directly or indirectly enhance service delivery.This includes collaborations to enhance organizational operations – administration and human resources, for example – and collaborations to enhance service planning and delivery. Examples of such collaborations include shared administration, budgets, or administrative staff; shared infrastructure such as co-location; joint service planning, or joint program delivery such as single intake; inter-agency service protocols or case management for clients; and information-sharing. Figure 1 describes the continuum of types of inter-agency collaboration. The project focused on service collaborations because they relate directly to NPO capacity to promote health equality through effective services, and because community-based health and social service providers feel under increasing pressure to rationalize and integrate their services through collaborative strategies that may lead all the way to organizational amalgamation. FIGURE 1: CONTINUUM OF TYPES OF INTER-AGENCYCOLLABORATION, BYINTENSITY LESS INTENSE MORE INTENSE IN COMMUNICATION COOPERATION COLLABORATION INTEGRATION D E P E N INTER-AGENCY SHARED POLICIES OR SHARING RESOURCES INTEGRATED PROGRAMS, D E N INFORMATION SHARING PROTOCOLS FOR STAFF, DECISION-MAKING PLANNING, FUNDING C E DEALING WITH CLIENTS Adapted from Vanderwoerd, J. (1996). Service Provider Involvement in the Onward-Willow-BBBFProject: 1990- 1993.Better Beginnings, Better Futures Research Coordination Unit: Queens University WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 3 Inter-Agency Service Collaboration in the NPO Sector The initial focus was also restricted to non-institutional or community-based health and social service providers. The realities of the research eventually broadened this focus to include lessons learned from NPO service delivery collaborations involving institutional and other partners. Initially, this project restricted its attention to NPO inter-agency collaborations that involved formal working agreements. However, as the summary of findings in Graham (2007) shows, this restriction would exclude much of the valuable actual collaboration that is taking place among Toronto service agencies. The project explored several questions: • What assumptions or forces appear to be pushing local NPO service agencies to collaborate more in service delivery? • Does collaboration work? That is, does it result in better services, better client outcomes, than agencies working alone? • What is the state of collaboration among Toronto health and social service agencies? What are the forces shaping the amount and kind of collaboration we are currently seeing in NPO health and social service delivery in Toronto? • On the assumption that collaboration can work, at least sometimes, what policies and policy supports promote collaboration that improves services and client outcomes? • On the assumption that collaboration can work, at least sometimes, what do NPO service agencies need to know about when and how to build collaborations that will work, that is, improve services and client outcomes? METHODS The project explored these questions using a multi-method approach. Scans of the research literature were conducted in all topic areas. The literature searches included both academic and gray literature. Information from the literature reviews was enriched through interviews conducted with key informants who have intimate knowledge of the goings-on within the sector. These included Toronto capacity builders, NPO collaborators, and other sector experts. Case studies were employed in order to gain insight into the process of collaboration. The East Scarborough Storefront Project provides a successful example of a collaboration that has survived the funding rollercoaster, while the case of the Korean Interagency Network provides insight into the process of forming a collaborative arrangement. Finally, a roundtable was held with local capacity builders, experts, officials from all three levels of government, and service providers. At the roundtable, participants expressed their reactions to the reports and discussed issues they felt are important for NPO collaboration. Asynthesis of the learnings from the roundtable has been included in the report. WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 4 Inter-Agency Service Collaboration in the NPO Sector OVERALL FINDINGS The current enthusiasm for collaboration in the NPO sector suggests many stakeholders already endorse collaboration as a strategy to increase NPO sector capacity and effectiveness – perhaps even as a “magic bullet” to achieve these ends. For these stakeholders, the key question to ask about services-related collaboration in the sector is not whether collaboration is an important strategy to improve outcomes, but how services-related collaborations should be encouraged and sustained. Academic and community researchers appear to share this perspective, focusing their work largely on the process questions of how to create and sustain good working collaborations (Boutilier et al. 2007). Taking this widely held view as a working hypothesis, the project’s initial investigations aimed to clarify and substan- tiatethe objectives and impacts – on clients, communities and services – of NPO service-related collaborations, and to identify process and policy strategies to promote collaborations that would improve outcomes for clients, communities and services in Toronto. The first overall finding of the project, however, was that a clear case has yet to be made for collaboration as a strategy to build the capacity of NPO services to improve client and community outcomes. Specifically, the project found: a. Alack of research evidence on the impact on clients, communities, and services of different types of service collaborations (Figure 1), due to a lack of outcome evaluations of individual service collaborations in both the academic research and grey literature (BOUTILIER ETAL. 2007). b. Alack of shared, clear understanding among Canadian stakeholders of what NPO services-related collaboration is intended to achieve (HOWARTH 2007; GRAHAM 2007).NPO service providers depend primarily on governments for funding, and to some extent on foundations and NPO funders such as the United Way. (In Ontario, the Province funds about 80% of NPO health and social services.2) Government funders’ ambitions for collaborative service delivery in the sector are not clearly articulated, and perhaps not well defined (HOWARTH 2007). But there is some evidence, and a widespread perception within the NPO sector, that funders’and providers’goals are often at cross-purposes: many funders are perceived to promote collaboration to rationalize and reduce duplication in existing services, while community-based providers say they most often collaborate to leverage resources in order to respond innovatively to complex community needs (HOWARTH 2007; GRAHAM 2007). The second overall finding of the project, however, was the outline of a “bottom-up” approach to NPO collaboration that has potential to increase collaboration and improve outcomes for clients and communities. This approach 2Katherine Scott, Spyridoula Tsoukalis, Paul Roberts, and David Lasby, The Nonprofit and Voluntary Sector in Ontario: Regional Highlights of Nonprofit and Voluntary Organizations.(Toronto: Imagine Canada and Canadian Council on Social Development, 2006) p.20. WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 5 Inter-Agency Service Collaboration in the NPO Sector emerged from local capacity builders, community-based providers, funders and other stakeholders in key informant interviews and roundtable discussions, and from additional research on collaboration in business and government. These investigations found: a. Sustainable service delivery collaboration that is perceived to have positive impacts on clients and communities is typically “bottom-up” – that is, it originates among service providers, strongly motivated, who come together to respond to a need. Funder-mandated or -incented collaborations, or collaborations in which agencies are not highly motivated to participate, or which lack a clear “value proposition” (some clear result each participant is seeking from the collaboration) are hard to create or sustain, and unlikely to improve outcomes for clients and communities (Graham 2007; Roberts 2007; Roche and Roberts 2007; Roundtable Proceedings). b. Bottom-up collaborations most often form to respond to complex community needs rather than to increase efficiencies or rationalize services for their own sake (GRAHAM 2007; ROCHE AND ROBERTS 2007; ROUNDTABLE PROCEEDINGS). This impetus for collaboration may explain in part why most collaboration among Toronto health and social services agencies continues to consist in informal information-sharing, followed by shared protocols and processes to link clients to services, and why there is relatively little of the back-office consolidation (e.g. shared ITsystems), the rationale for which is typically efficiency-based. c. The NPO sector’s bottom-up impetus to collaborate shares interesting parallels with private sector collaboration. Business collaborations are aimed often as not at increasing firms’long-term profitability in complex, intensely competitive globalized markets – a strategic goal – rather than at increasing short-term profits through increased efficiencies (ZIZYS 2007). That is, like NPO collaborations, business collaborations also often aim to leverage resources to respond innovatively to their complex environments. Moreover, the response of both business and NPO collaborations is often to bring together different core competencies within the different organizations to respond innovatively to the complex environment (GRAHAM 2007; ZIZYS 2007). One important difference between business and NPO collaborations, of course, is business’s focus on narrow, limited ends in collaboration. Business is the only sector for which there is considerable evidence that collaboration improves outcomes – both strategic (at least for simple collaborations) and short-term financial outcomes (ZIZYS, 2007). Arguably, the private sector’s success with collaboration motivates and guides governments’current efforts to increase collaboration within the public and NPO sectors. The success of strategic private sector collaborations in improving outcomes therefore provides some indirect rationale, for NPO services-related collaborations improve outcomes for clients and communities. However, the differences between NPO and business collaboration also suggest caution in generalizing the business experience to the NPO sector. d. There would be more collaboration if agencies had more financial and other resources to build and maintain labour-intensive collaborations, and if government’s and other funders’policies toward the NPO sector were WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 6 Inter-Agency Service Collaboration in the NPO Sector more collaboration-friendly (GRAHAM 2007; EAKIN 2007; ROUNDTABLE PROCEEDINGS; ROCHE AND ROBERTS 2007). Community-based providers are keen to collaborate where it will meet community needs, even though they are also skeptical of policy-makers’and funders’goals for NPO collaboration, and want solid evidence that their collaborations improve outcomes (GRAHAM 2007). Funders’intense concern with funding accountability reduces agencies’ability to collaborate by consuming enormous agency resources in applying for, and reporting on, funding (EAKIN 2007). This intense concern with funding accountability reinforces NPO perceptions that government sees collaboration as a strategy to contain costs by increasing efficiencies. Un-standardized funder policies and procedures, and lack of direct funding for collaboration even when mandated, also reduce the resources for collaboration (GRAHAM 2007; EAKIN 2007; BANASIAK 2007). Skills training to providers on how to create and sustain collaborations would also increase sustainable collaborations (ROBERTS 2007; GRAHAM 2007). e. Intensive collaborations that involve shared resources, activities, and /or authority (see Figure 1) very often coalesce out of informal information-sharing among agencies, or the ongoing activities of sector networks, alliances and other project partnerships (GRAHAM 2007).These other collaborative activities also need to be nourished for services-related collaborations to increase. There is a pressing need for more evidence that collaboration enhances NPO sector capacity to improve outcomes for clients and communities. More substantial evidence is also needed on which types of collaborations (Figure 1) improve outcomes, and in what contexts. In the interim, though, some indirect evidence from the private sector, and anecdotal evidence and ongoing commitment to strategic collaboration from providers, as well as other stakehold- ers, present some rationale for moving forward in promoting collaboration as appropriate. The most promising approach to increase levels of collaboration in NPO services, and to increase the kinds of collaborations most likely to improve outcomes, is for all stakeholders to work together to create a policy and practice environment that best nurtures bottom-up collaborations that evolve to respond to complex community needs in innovative ways. This involves re-orienting efforts away from collaboration imposed as a top- down strategy to rationalize existing services for its own sake. What evidence we have suggests that such collaborations are more likely to wither and die, and therefore less likely than organic collaborations to improve outcomes for clients and communities. Positively, it involves NPO-friendly policies, more research evidence on what works, and entrepreneurial action within the sector that will facilitate more organic collaboration and remove barriers to its bottom-up development. Key informants and roundtable participants had some specific suggestions for action. These are highlighted in the final section. WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 7 Inter-Agency Service Collaboration in the NPO Sector DETAILED FINDINGS This section describes the findings from the research in more detail. The findings are organized under headings that largely respond to the research questions that guided the investigations. (Individual reports can be read in their entirety after this chapter.) 1. THE GOALS AND OBJECTIVES FOR NPO SERVICES-RELATED COLLABORATION There is a widespread perception in the NPO sector that funders – primarily governments – want more collaboration, and more intense collaboration (Figure 1) among NPO health and social services. For example, the newly formed Local Health Integration Networks [LHINs] have a mandate to integrate services within Ontario’s 14 regional health care authorities, including those community-based health services they coordinate and fund. These policy trends raise the spectre of organizational amalgamation for sector providers. For funders, the more limited integration of specific planning, program delivery, or administration functions among several agencies might be viewed either as an alternative to full amalgamation, or a way-station to that result. Ascan of federal, provincial and City of Toronto policy statements on collaboration among NPO community service organizations, and between government and the sector(HOWARTH 2007),however, found: a. Government’s rationales for collaboration with the NPO sector identify multiple goals, from improved service access to increased civic engagement. However, there are no similar stated rationales for collaboration within the NPO sector (although the difference between “with” and “within” is not always noted). b. Program-level policies for the NPO sector consistently call for more partnerships and collaboration among agencies. The focus here is solely on service delivery. The goals and objectives for collaboration seem to be: improved service delivery effectiveness and impact through, for example, reduced service duplication: increased service coordination for clients: and streamlined access[HOWARTH 2007]. c. Government makes no clear statement, at either the policy or program level, about which types or intensity of collaboration (Figure 1) it thinks is needed. However, even initiatives directed to increasing service integration, such as the LHINs, do not call for agency amalgamations [HOWARTH 2007]. In key informant interviews, capacity builders, providers and researchers indicated that community-based agencies have traditionally collaborated, mostly in informal information-sharing. They felt that community-based agencies want to collaborate more often and more intensively (Figure 1) wherever doing so will leverage more resources to respond to the complex needs that agencies face (GRAHAM 2007). WELLESLEYINSTITUTE | ADVANCING URBAN HEALTH PAGE 8