Lutheran Social Services of Illinois

Putting Design at the Heart of Social Service Delivery

In the United States, the effectiveness of social services like state-funded medical care, mental health services, housing support, and access to food is largely tied to a broader social service delivery system defined by government policy. Unfortunately, it’s not always easy to institute policy in a way that serves the myriad needs of the people accessing these services. And social service agencies typically don’t have access to the innovations that make life easier through technology.

While a single social service organization is equipped to help someone who seeks support, the larger system of care providers is structured in a way that makes it difficult for them to collaborate and communicate about a person’s needs in a holistic way. This makes it hard for case managers who plan and coordinate treatment options for clients to address individual needs with consistency, and it creates hurdles to helping those in need. Ultimately, case managers need the tools to be able to fully support their clients at each step along their treatment paths in the most efficient and empathetic ways possible – this is lacking in many cases.

These are some of the challenges that Lutheran Social Services of Illinois (LSSI), the largest social service organization in the State of Illinois, faces daily. And so, Fjord teamed with LSSI to explore how technology could eliminate fragmentation and strengthen care coordination within the network that LSSI and 190 other Illinois social service organizations belong to. In this way, Fjord was able to bring design into a space, and to people, who generally aren’t its focus, putting service design and innovation at the heart of social services.

We found that you listened to us about making connections within the network and really designed a means by which we could view what was happening in the life of a person. I mean, how cool is that?
Mark Stutrud CEO, LSSI
Supporting a Holistic Approach to Care

LSSI provides mental health services and alcohol and drug treatment, along with several other vital social services to Illinois residents who generally live below the poverty line. People learn about LSSI through referrals from family, friends, or care providers who are familiar with the type of services the organization offers. A person’s first interaction with LSSI takes place when they seek service voluntarily at an LSSI site or via a referral. In addition to office consultations, LSSI case managers visit new clients in the hospital or in their homes.

To better understand social service delivery at LSSI, Fjord had to build a deep understanding of its integrated healthcare approach called Whole Person Care, which focuses on treating the spectrum of health, mental, emotional, and social needs that factor into a person’s overall wellness. Other social service agencies and healthcare providers also take this approach.

We observed that Whole Person Care was reliant on a network of social service providers that isn’t currently integrated to its fullest potential. Specifically, there wasn’t a way to track a person’s journey as they moved between social service agencies – so, for example, supporting a mentally ill client, who might also be homeless, became difficult when that client was referred to a housing agency outside of LSSI. Additionally, communication about treatment involving services as varied as food, housing support, or medical care was breaking down as clients utilized different services. Coupled with disparate record-keeping systems, this created fragmentation across the network. Furthermore, it was difficult for LSSI to consistently communicate how the network was working for its clients without doing a deep dive into client records or data sets.

To remedy this, Fjord designed a tool called the Whole Person Care Journey that helps case managers better coordinate the care of their clients. The tool also provides a way to gather analytics on the health of the network, or which services are working best for clients, in a system where it’s currently difficult to quickly assess return on investment. We explored this value that the tool promised by demonstrating how elements of our design would work across programs via a low-fidelity digital application and worked closely with caseworkers to refine the design throughout the demonstration period.

Three distinct features of the Whole Person Care Journey tool aim to make care coordination easier for case managers and more empathetic toward the people accessing social services.

1. The “Warm Welcome”

Most people can relate to how impersonal it feels to be one in a long line of patients in a doctor’s office. For LSSI’s clients, many of whom find themselves in crisis situations, this sense of alienation is even more pronounced. To address this, Fjord designed an appointment check-in process that could at once help clients feel welcome at their appointments and collect information for case managers about their clients’ progress. Using an easy-to-generate visual code embedded with “anonymized” data, clients are able to scan a care ticket, or a sticker attached to a personal item, to check in at appointments within LSSI’s care network. This “warm welcome” replaces the more conventional sign-in process that is typically an impersonal, administrative transaction, in which you write your name on a public list or spell your name out loud, with one that feels more like a “hand shake” between a person and their care provider. The tool’s check-in view displays non-sensitive personal information that enables the provider to greet their clients more warmly – like they are known to the organization they are visiting and that their appointment is important. We know that treatment isn’t viewed as “fun” for most people and believe that the way they are welcomed can help them approach seeking support more positively.

2. A Visual Journey Through Treatment

During our demonstration, caseworkers had access to a digital timeline, or a visualization of their client’s progression through treatment that was constructed using client check-in data. Unlike electronic health records or communications that case managers receive via email or phone, the visual Whole Person Care Journey allows case managers to more quickly determine if their client successfully linked to another social service provider or if a particular activity, like a trip to apply for SNAP benefits, was a factor that contributed to staying on the most successful path for them. In addition, case managers saw the digital journey view as a way of enhancing their communication with clients and keeping them accountable for meeting their own goals.

3. Network Health Analytics

Supporting successful client stories with hard numbers that could be aggregated, viewed, and readily shared with others was time consuming for LSSI. This information is especially important in demonstrating the success of Whole Person Care to payers, the government, or internally to stakeholders. To address this, Fjord designed an analytics feature that aims to provide administrators with a high-level view into the types of success metrics that matter the most across the care network. It’s also a quick way to conduct a pulse check of the “health” of a care network (which currently involves a tedious paper trail) to see if providers are working together effectively.

Our Partnership

Fjord found that the best way to build on the strength of LSSI’s work was to use an empathetic approach to design that relied heavily on designers and decision-makers forming a close working relationship. We were able to infuse more empathy into our process by designing and demonstrating the Whole Person Care Journey in real-time with case managers who had first-hand knowledge of what it’s like to work in this arena.

While working with LSSI, we interviewed case managers and shadowed employees in group homes, in an emergency room at a Chicago hospital, and at an alcohol treatment center. We spoke with a range of people, from the directors who hold the care network together, to the case managers who are on the ground seeing clients every day. Working with the people who would be using the tool set the tone for our collaborative approach.

We also learned that in the face of government funding decisions, the world of social service provision changes often, if not daily. We wanted to confirm that our tool would hold up in the face of any turbulence, and, most importantly, would support the way in which care providers and clients already work.

A Network Is Only as Strong as the Sum of Its Members

Weaving together the services offered to one client by disparate social services organizations makes it difficult for providers to communicate, collaborate, and to address their clients’ requirements with consistency. Improving service delivery across organizations is not an easy task, and there are more barriers to success, especially when it involves services that are administered on a large scale – like with LSSI. The Whole Person Care Journey aims to address these difficulties and gives case managers a different view into how their clients access social services.

The populations with which case managers work are generally not beneficiaries of good design. Their circumstances don’t allow them access to the innovations that make life easier for those who have the privilege of always having technology at their fingertips. By working closely with LSSI, Fjord was able to bring design into a space, and to people, who generally aren’t its focus, putting service design and innovation at the heart of social services.

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