""'
" .
Department Of Health And Human Services 
OFFICE OF 
INSPECTOR GENERAL 
SERVICES INTEGRATION: 
A TWENTY-YEAR RETROSPECTIVE 
of 
E.r. CI.r Richard P. Kusserow 
INSPECTOR GENERAL 
It.. 
i J  .. JANUARY 1991 
Jy~  ...--...--.",... ., 
,;"  . .
OFFICE OF INSPECTOR GENERAL 
Inspector General (DIG), as mandated by Public Law 95-452

The mission  of  the Office  of 
Health and Human Services

as amended, is to protect the integrity  of  the Department  of 
beneficiaries served by those

(HHS) programs as well as the health and welfare  of 
programs. This statutory mission is carried  audits,

out through a nationwide network  of 
investigations, and inspections conducted by three DIG operating components: the Office

Evaluation and

of  Audit Services, the Office  of  Investigations, and the Office  of 
program and management

Inspections. The DIG also informs the Secretary  ofHHS of 
problems, and recommends courses to correct them.

OFFICE OF AUDIT SERVICES 
The DIG'  Audit Services (OAS) provides all auditing services for HHS, either by

s Office  of 
conducting audits with its own audit resources or by overseeing audit work done by others.

HHS programs and/or its grantees and contractors in

Audits examine the performance  of 
carrying out their respective responsibilities, and are intended to provide independent

HHS programs and operations in order to reduce waste, abuse and

assessments  of 
mismanagement and to promote economy and efficiency throughout the Department.

OFFICE OF INVESTIGATIONS 
The DIG'  Investigations (01) conducts criminal, civil, and administrative

s Office  of 
wrongdoing in HHS programs or to HHS beneficiaries and

investigations  of  allegations  of 
01 lead to criminal

of  unjust enrichment by providers. The investigative effons  of 
convictions, administrative sanctions, or civil money penalties. The 01 also oversees State

Medicaid fraud control units which investigate and prosecute fraud and patient abuse in the

Medicaid program.

OFFICE OF EVALUATION AND INSPECTIONS 
The OIG'  Evaluation and Inspections (OEI) conducts shon-term management

s Office  of 
concern to the

and program evaluations (called inspections) that focus on issues  of 
Department, the Congress, and the public. The findings and recommendations contained in

the inspections reports generate rapid, accurate, and up-to-date information on the

dep~ental programs. This repon was

effici~ncy, vulnerability, and effectiveness  of 
Regional Inspector General

prepared in the Boston Regional office under the direction  of 
Mark R. Yessian, Ph.D., and Deputy Regional Inspector General Martha B. K vaal. Project

staff include:

Dana L. Miller 
Barry C. McCoy 
Eleanor M. Ellis 
Nina M. Ricks

Headquarters

Ruth Folchman,  """ 
...",, 
Department Of Health And Human Services 
OFFICE OF 
INSPECTOR GENERAL 
SERVICES INTEGRATION: 
A TWENTY-YEAR RETROSPECTIVE 
Richard P. Kusserow 
INSPECTOR GENERAL 
~ OEI-
OI-91-00580 
Jy.l~""'Ja  -"'
, "--- ".-. ....
___0.'__" 
EXECUTIVE SUMMARY

PURPOSE 
In the 1970's and 1980's, the Department of Health, Education, and Welfare (HEW) and its 
successor, the Department of Health and Human Services (HHS), have taken many initiatives to 
promote a more integrated management and delivery of human services. In this study, we 
examine those initiatives to identify major lessons learned that can help guide policymakers in 
the 1990's. In so doing, we pay particular attention to comprehensive initiatives which have 
spanned different categorical programs. 
BACKGROUND 
is a response to the highly fragmented nature of the human services 
Services integration  (SI) 
environment. It involves effons at service delivery and administrative levels to establish 
linkages that contribute to the effectiveness, efficiency, and economy of human services 
programs. Over the past two decades, there has emerged a considerable body of .
literature that 
describes and assesses these SI effons. In this repon, we base our findings and concluding 
observations on a review of much of that literature and many internal HEW/HHS documents, 
companion report, "Services Integration for Families and Children in Crisis 
(OEI-09-90-00890), identifies and analyzes 13 SI effons initiated at the community level to 
assist dysfunctional or multiproblem children and families. 
FINDINGS 
efforts have been instrumental in making human services more accessible to clients and 
SI 
more responsive to their needs. 
Over the long term efforts appear to have had little institutional impact on a 
, however, 
5,1 
highly fragmented human servil!es system. 
efforts that cut across program areas confront fundamental barriers. They include: 
SI 
1. Size and complexity of the human services system. 
2. Professionalization, specialization, and bureaucratization. 
3. Limited influence of integrators, 
4. Weak constituency for services integration. 
5. Funding limitations.  -. "'--"--"'" . ...._---.. --"-..
6, Insufficient knowledge. 
PRINCIPLES FOR FUTURE SI EFFORTS 
Given the enormity of the barriers they face, Sf efforts that callfor major institutional reform 
should be initiated selectively, if at all. 
An Sf strategy likely to generate more near-term success is to focus on well-defined target 
groups and to pursue reform primarily within categorical program areas. 
Even a target-group, categorical-program approach, however, is likely to require some degree 
of central authority and flexible funding to generate and sustain more integrated service 
delivery. 
A funding source granting an organization some authority and flexible funding for promoting 
Sf should hold it accountable for defining and measuring expected outcomes. 
The cultivation and maintenance of networks of individuals engaged in Sf efforts is vital to 
the success of these efforts.  ........................................... .. .......... .. ...........-....  . .-.... ...."......'..-...-...-...".....-...'......-.........  .......... ............. .". ."..."......"....,.. ............................................  ................................. .'..."..........,. ,...---...-.....
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
CH APTER I: INTRODUCTION 

The Meaning of Services Integration .............................. .............. ................................... 

The Historical Background ..............................................  :..........".... ". 2

CHAPTER II: OVERVIEW................ ...................................... .................... ........................ .., 5

Findings.................... ...... ............  """""""""""""'.'."""'.""..."".."""" 5

Principles for Future 51 Efforts  :..................... ........ ........ .............. ...... ........... 8

CHAPTER Ill: DEFINITIONS OF SERVICES INTEGRATION ...................................., 10

CHAPTER IV: CHRONOLOGY OF MAJOR FEDERAL SERVICES 
INTEG RATION EFFORTS ...... 
CHAPTER V: FINDINGS FROM SELECTED NATIONAL STUDIES ON

SERVICES INTEGRATION ................................... ............... ............ ...... ...... ............ ...... ......' 15

, APPENDIX A

Endnotes....,........................................... ..............................................................,......... A- --, "'--"-'
INTRODUCTION 
CHAPTER 
During the past two decades, the Department of Health, Education, and Welfare (HEW) and its 
successor, the Department of Health and Human Services (HHS), have initiated many efforts to 
promote services integration (SI). In this repon we review those efforts with the aim of 
determining what has been learned from them. Our presentation is a succinct one directed to 
Federal policymakers who are considering Federal SI initiatives that might be taken in the early 
1990' 
We start out in this introductory chapter by providing some conceptual and historical context. 
We examine. the meaning of SI and the historical backdrop of 51 efforts in HEW/HHS. Then, in 
Chapter II, we offer an overview of our findings and of what we conclude are some basic 
principles that should guide SI effons in the 1990' 
The subsequent chapters provide more detailed infonnation that help explain and support the 
findings and principles set forth in the overview chapter. In chapter III, we cite various 
definitions of 51. In chapter N, we present a chronology of major 51 efforts in the 1970' s and 
1980' s. Finally, in chapter V, we list the major findings from selected national studies on 51. 
Throughout the repon, we rely primarily on a review of the considerable literature that exists on 
the topic. We also draw on the files and experiences of the primary author, who has participated 
in many Federal SI activities over the past two decades. 
A companion report, "Services Integration for Families and Children in Crisis" (OEI-09-00890), 
on SI initiatives undertaken at the community level. It describes and analyzes 13 such 
focuses 
initiatives that address the.needs of dysfunctional or multiproblem children and families. 
THE MEANING OF SERVICES INTEGRATION 
Many years ago, the story goes, an HEW employee was assigned to a task force on services 
integration and, at the initial meeting, turned to the person next to him and asked why they 
would be examining racial integration in the armed forces. Whether true or not the story 
illustrates an important point: th~t 51 has had different meanings to different people. 
Sf At Service Delivery Levels 
2 have found it helpful to distinguish between 51 
In reviewing these meanings, we and others
efforts conducted at service delivery levels and those at administrative levels. Most definitions 
on the delivery levels, where individuals and families come into contact 
(see chapter Ill)  focus 
with the service delivery system. They stress the linking of service providers or programs in 
order to improve the system  from 
s responsiveness to client needs. These linkages may range 
the integration of core services such as outreach or intake, through the development of case 
management services, to the sharing and/or collocation ' of personnel.  In this context, SI is viewed as a response to the basic failings of the human services delivery 
system. In 1974, in a special report on SI issued by the American Society for Public 
Administration, these failings were described as follows: 
The system is too fragmented, leaving clients with multiple needs unnecessarily 
vulnerable. 
The goals of individual programs are too limited. Shaped by the categorical mandates of 
authorizing legislation, they inhibit broadly based, multifaceted approaches to problem 
solving. 
The services are often provided ~'in an inefficient, duplicative, and bureaucratically 
confusing manner to those who have the need. 
The services tend to be lacking in accountability and to be self-perpetuating, regardless 
of their effectiveness. 
The service system is not sufficiently attentive to the long-term needs of clients. 
At Administrative Levels 
SI 
At administrative levels, the focus is on linking providers and programs to improve planning, 
budgeting, and management operations. Here, the empbasis is on achieving greater 
administrative coherence, with the intent not only of facilitating service level effectiveness but 
also of promoting efficiency and economy. 
In this sphere, SI is typically viewed as a way of using business principles to enhance 
accountability and productivity. Specific initiatives might range from the consolidation of 
various categorical programs through the imposition of more general management controls over 
such programs, to the conduct of joint planning and programming efforts. 
At both service delivery and administrative levels, SI is a response to increased specialization 
and complexity. It is an effort to view human services from a higher level of generality and in so 
doing to spot opponunities for reform that are not readily discernible from narrower vantage 
points. In this sense, SI is comparable ,to a business firm changing its focus from shoes to 
footwear or from business equipment to information processing. By raising the level of 
generality at which it defines its products, such a firm seeks new profit-making opportunities in a 
changing marketplace. 
THE HISTORICAL BACKGROUND 
In the 1960' s, as the Federal Government was fighting a "War on Poverty" and increasing its 
investment in human services programs, it began to devote substantial attention to the 
coordination of services. In the Juvenile Delinquency, Neighborhood Service Center 
Community Action , Model Cities, Community Mental Health Centers, Head Start, Older 
Americans Act, and other programs, Congress stressed the importance of coordinated planning  and service delivery, In this regard, it was pursuing objectives sought many decades earlier by 
the organized charity and settlement house movements. 
1971-1976 
By the early 1970' s, HEW, which had not been a major participant in the "War on Poverty 
6 There were two 
effort, began to give concened top level attention to service coordination. 
precipitating factors. One was the intent, supported by the President to separate the 
'1 With such separation 
administration of income maintenance and social services programs. 
social services and how they were delivered would gain increased visibility. The other factor 
was Secretary Elliot Richardson s interest in initiating reforms that would foster the integration 
of services across categorical program areas. In speeches, Secretary Richardson often lamented 
that these programs were suffering from a "hardening of the categories. 
In defining what he came to call "services integration " Richardson stressed the importance of 
the service delivery level, both as a point to make a difference in the lives of needy individuals 
and as the wellspring for associated reforms at higher administrative levels, During his tenure 
the Secretary initiated an ambitious SI agenda involving research and demonstration projects, 
prop,osed legislation, technical assistance effons, and internal depanmental reforms (see chapter 
8 , 
IV). 
When Caspar Weinberger became Secretary in early 1973, he and Under Secretary Frank 
Carlucci continued to give considerable attention to SI. Increasingly, however, they focused 
9 and on 
their effons on the integrative potential of State and local general purpose governments 
the importance of strengthening the human services planning and management .
capacity of these 
governments. 
In this context, both the Richardson and the Weinberger teams saw particular value in umbrella 
State human services agencies as spearheads for SI and, through research grants and technical 
assistance effons, supported the development of such agencies,. These umbrella agencies, 
defined by the Council of State Government, brought together under central management (of 
varying degrees of authority) the agency that administers public assistance/social services and at 
lO By far the most noted of the umbrella 
least three other major human services programs. 
agencies was in Florida, where in 1975 the State legislature gave generalist managers in the State 
Department of Health and Rehabilitative Services far more control over categorical programs 
than in a~y other State. 
1977-1990 
By 1977, when Joseph Califano became Secretary of HEW, the Department s SI effons were 
losing momentum. The proposed Allied Service Act, the keystone of prior SI agendas, had 
failed to pass Congress, despite repeated attempts. Further, various HEW-supported research 
projects and internal reform efforts were having little institutional impact.  ' " " "
In any case, the new Secretary s priorities were elsewhere, Programmatically, he concentrated 
on attempts to achieve welfare reform and national health insurance, Organizationally, he 
triggered internal reorganizations that stressed centralization and functional management. 
In the late 1970's and throughout the 1980' s, the SI agenda devolved largely to State and local 
governments. With Congress' enactment of the social services block grant in 1975 and seven 
additional block grants in 1981 , States faced fewer categorical program constraints and thus had 
greater flexibility in using Federal funds to promote SI. The Federal funding cutbacks and the 
economic recession of the early 1980' s, however, clearly limited this opportunity. For example, 
a fall 1985 anicle on New Jersey s experience with block grants noted that the funding shortfalls 
had limited the State and county governments  ability to be flexible and innovative.  The 
shortfalls in funding," the anicle went on  have negated any positive effect the reductions of . 
regulations and controls may have had. 
Further, in the 1980' s, interest in establishing or strengthening State umbrella agencies waned 
considerably. The gains associated with such efforts appeared to be too distant or intangible to 
I4 Governors, concerned about 
warrant the struggle to overcome the opposition they generated. 
the rising costs of Medicaid and other human services programs, increasingly exerted their 
influence over these programs through their State budget offices or their own immediate offices. 
In this regard their focus typically was not on service delivery reform but on expenditure control. 
Yet, without great visibility, SI efforts continued to take place in the 1980' s. IS Some of the more 
notable ones were sponsored by private foundations; others by governmental sources. In general 
these effons seem to have been less ambitious than those of the 1971-76 era. Increasingly, it 
appears, they involved integration within categorical programs and for target groups, such as the 
aged, mentally ill, runaway youth, and developmentally disabled. 
At the HHS level, Secretary Louis Sullivan has recently taken some actions that are consistent 
with this target group approach and that suggest that SI is again a secretarial priority. In the fall 
of 1990, the Secretary announced nine program directions to be implemented in fiscal years 
1991 and 1992. One calls for improving "the integration, coordination and continuity of the 
various HHS funded services potentially available to families currently living in poveny." Two 
others call for integrative efforts directed to youth and children living in poverty,  CHAPTER II:  OVERVIEW

FINDINGS 
In chapter V we provide a detailed review of the findings of many national SI studies conducted 
during the past two decades. Below, we offer at a more general level the major findings that 
have emerged from these and other studies. Throughout, the major focus is on comprehensive SI 
efforts that seek to establish aqrninistrative and service delivery linkages across program areas. 
SI Efforts Have Been Instrumental in Making Human Services More Accessible to Clients 
and More Responsive to Their Needs. 
Over the past 20 years, SI projects have made an important difference in the lives of many 
individuals and families having multiple service needs. In Brockton, Massachusetts; Louisville, 
Kentucky; Mon Valley, Pennsylvania; Honolulu, Hawaii; Hartford, Connecticut; and many other 
sites of demonstration projects, clients have benefited from a broadly based approach to service 
17 For instance, Hartford' 
delivery.  s Community Life Association project, one of the more 
ambitious SI research efforts funded by HEW in the 1970' s, delivered a wide array of services to 
more than 2,000 individuals and, suggests the final evaluation report, "in ways which would not 
have been possible if equivalent funds were applied through previously existing channels. 
At both administrative and service delivery levels, the development of new linkages between 
programs and service providers has often made it easier for clients to gain access to services and 
for caregivers to be more helpful in providing those services. Through information and referral 
systems, multiagency client information systems, joint programming efforts, and the like, SI 
projects to varying degrees have been able to cut across the fragmented human services system 
and respond in a coordinated manner to the service needs of clients. 
Over the Long Term, However, SI Efforts Appear to Have Had Little Institutional Impact on a 
Highly Fragmented Human Services System. 
The failings of the human services system identified in the 1974 report of the American Society 
19 Notwithstanding the new 
for Public Administration appear to be equally applicable today. 
block grant programs and the continuing contributions of Head Start and many other programs 
that have imponant coordinative components, that system remains highly fragmented, 
characterized by multiple programs with limited goals offering services that are often 
20 Not 
duplicative, lacking in accountability, and inattentive to long term client needs.
surprisingly, then, a 1987 General Accounting Office study found that substantial obstacles 
continued to inhibit SI initiatives, Among the most frequently noted were the multiplicity of 
regulations associated with human services programs and the different eligibility requirements of 
different programs. 
The history of the many SI demonstration projects funded over the years is that once the 
demonstration funding has run out, the integrative elements have receded or disappeared 
altogether, 22 Typically, they have exerted little institutional impact on the larger human services  ' ,,
system. The imperatives of specialization have proven to be more commanding and lasting than 
those of integration, 
SI Efforts That Cut Across Program Areas Confront Fundamental Barriers, 
In reviewing the SI literature produced over the past 20 years, we find that the clearest lessons 
learned are about the factors that inhibit services integration. These lessons can offer extremely 
valuable cautions to the architects of future 51 efforts. Below we identify and briefly address six 
basic barriers that have constrained SI efforts and that help explain the highly pluralistic state of 
the human services field. 
Size and Complexity of the Human Services System 
1, 
In 1972, an internal HEW task force identified size and complexity as one of the major obstacles 
to services integration, It elaborated as follows: 
The numbers of doors to open; the professional keys to open them; the mazes of
paperwork and human interaction; the length of time between conception of an idea and
All of these, in the aggregate, create a specter
fulfillment; the budgetary uncertainties. .. 
that is a challenge to the most sophisticated and dedicated local advocate of
integration. ,,
In subsequent years, the experiences of many SI projects reinforced the validity of the task 
force s observation, In 1977, in a Project SHARE mQnograph reviewing these experiences, the 
author concluded that "the reality of interprogram linkages is so complex that it is difficult for 
anyone to anticipate the full ran coordination and the number of possible 
modes  of 
,r;e of possible 
impediments to coordination. 
Professionalization, Specialization, and Bureaucratization 
2. 
These three forces are a basic part of the human services system and, for that matter, of modern 
Western society. They are an interrelated set of forces that reflect the rapid advance of 
knowledge and a quest to apply that knowledge in a proficient, reliable manner to meet human 
needs. At the same time, these f9rces contribute to a deep commitment to established doctrines 
and approaches. Bureaucracy, by its very nature, reflects a bias toward the status quo,25 and, as 
J. Laski pointed out 60 years ago, the "intensi~ of vision" associated with professionalism and 
specialization "destroys the sense of proportion, " 6 In the domain of SI, project after project has 
found that the highly professionalized, specialized, and bureaucratic nature of the human 
services environment generates a mind-set among established interests that is not receptive to 
integrative reforms. Here, again, an early study reflected an insight that subsequent experiences 
have strongly reinforced, In a pioneering 1971 HEW report on SI, the authors expressed the 
view that "attitudinal barriers to services integration were much more significant than were 
resource constraInts or even envIronmenta comp exIty In uman serVIces programs,  Limited Influence of Integrators 
3, 
In the early 1970's, those developing SI strategies at the Federal level viewed the collaboration 
of functional line agencies as crucial, but in itself insufficient. For SI efforts to take hold, they 
felt it was necessary for some integrator, having a broader perspective, to exert leadership, Thus, 
they emphasized the significant contributions that must be made by representatives of general 
purpose governments and by those directing SI projects. 
The cumulative history of these projects, however, indicates that over time the integrators have 
29 In part, this is because of all the other barriers noted, but it is also because' 
limited influence.
of the instability of the integrator roles. Leaders of SI demonstration efforts have found the 
career track in such roles to be extremely limited, panicularly in contrast to that of their 
colleagues in specialized agencies. Similarly, human services generalists associated with general 
purpose governments have tended to have shon tenures, coming and going in response to the 
vicissitudes of electoral politics. 
Weak Constituency 
4,  for Services Integration 
Another barrier, one that further explains the limited influence of generalist integrators, is the 
weak constituency that exists for SI. The strongest constituencies within the human services 
field are those that rally around specific target groups, such as the disabled, the mentally 
retarded, and the aged, and around particular programs serving those groups. In contrast, those 
supporting SI efforts tend to be diffused and with rare exceptions less forceful in their advocacy, 
Thus, SI has rarely been a offic~als, government executives, service 
Rriority among elected 
providers, or even clients, Whatever its substantive merits, SI has lacked the political 
constituency to sustain major reform
, especially in heavily urban areas with a multitude of 
32 This is a lesson that SI supponers have often learned the 
well-established service providers.
hard way. When their efforts have generated the conflict that is an inevitable part of the change 
process, they have usually found that the balance of power is not in their favor. 
Funding Limitations 
5. 
, its advocates have typically argued, is not a quick-fix for the failings of the human services 
system, but rather an investment toward enduring reform, with significant long-term impact. 
This investment is one that has usually called for an increased expenditure of funds, over and 
34 These additional funds have been vital 
above those being spent on current service operations.
to the establishment of SI mechanisms such as client information systems, collocated services, 
and case management arrangements. 
Yet, during times of taxpayer revolts, fiscal stress, expanded client need for direct services, and 
heightened competition for public dollars, such investment capital has been available only on a 
very limited and irregular basis. This is especially true because the track record of SI efforts is 
that they do not appear to contribute to reductions in service costs, at least in the near term, 
Thus, funding limitations have served as a major constraint to both the initiation and the 
continuation of SI reforms,  Insufficient Knowledge 
6. 
Is SI cost-effective? Are the additional costs imposed by linkages warranted on the basis of 
outcomes? Are certain types of linkages more important than others? Why? Under what 
circumstances? Even after two decades of experimentation, few reasonably conclusive answers 
can be offered to these and other such basic questions. That reality continues to exert one of the 
most significant barriers to SI. 
With varying degrees of rigor and completeness, such questions have been addressed by some 
individual project evaluations. At a national level, however, there has been insufficient data 
gathering, synthesis, or analysis to offer policymakers much guidance. In this regard, three of 
the major SI research and development efforts funded by HEW /HHS over the past two 
decades-the Services Integration Targets of Opportunity, the Comprehensive Human Services 
Planning and Delivery System Projects, and the Services Integration Pilot Pro~ects-have fallen 
far short of their own stated intentions to contribute. to the SI knowledge base, 6 
PRIN CIPLES FOR FUTURE SI EFFO RTS 
Those planning and conducting SI efforts in the 1990's face a challenging situation. As they 
look back at the effons of the past two decades, they can find much more information on the 
possible pitfalls than on the particulars of how they should approach SI or on the results they can 
levels, 
prior experiences do offer a base of 
expect. Yet, although providing no easy answers, these 
wisdom that, at least at a general level, can be instructive. We offer some principles intended to 
draw on this wisdom and to provide some guidance to future SI efforts at Federal, State, or local
Given the Enormity of the Barriers They Face, SI Efforts That Seek Major Institutional 
Reform ShQuld Be Initiated Selectively, If At All. 
The HEW SI agenda of the 1970's sought far-reaching institutional reforms in the human 
services system. Many of the initiatives developed were comprehensive ones, spanning 
categorical program areas, seeking new lines of authority, and calling for a substantial 
expenditure of funds. Although ,it is possible that long-term gains may justify such expansive 
efforts, the prospects for generating and sustaining the necessary political, programmatic, and 
financial support are not good. The chances of success appear to be much greater if 
policymakers pursue more modest objectives, stressing incremental, near-term gains. 
An SI Strategy Likely To Generate More Near-term Success Is To Focus On Well-Defined 
Target Groups And To Pursue Reform Primarily Within Categorical Program Areas, 
Such an approach is grounded in the current realities of the human services system, Although it 
may not change some of the basic failings of that system, it would receive more support from 
established constituencies and could, if short-term results were favorable, generate momentum 
38 Further, by virtue of being less complex
toward more far-reaching reform, , such a strategy 
would facilitate priority-setting and performance assessment. In this regard, it responds to Peter  39 
Drucker s warning that "government will mal perform if an activity is under pressure to satisfy, 
different constituencies with different values and different demands. 
Even A Target-Group, Categorical-Program Approach, However, Is Likely To Require Some 
Degree Of Central Authority And Flexible Funding To Generate And Sustain More Integrated 
Service Delivery, 
A danger associated with a more modest approach to SI is that it will not sufficiently change 
established patterns of administration and service delivery. Coequal agencies, we have found, 
tend to participate in integrative efforts warily, if at all. If an integrative effort of some 
consequence is to occur and endure-for instance, one directed to clients who suffer from severe 
mental illness as well as from alcohol and drug abuse-it would appear to be necessary for an 
integrator to provide some external stimulus and for the participating agencies to agree to some 
40 So, too, there should be some degree of flexible funding to support the 
loss of sovereignty.
effort, at least at the outset. In the words of one 20-year veteran of SI initiatives, " , . . nothing 
coordinates like cash. . . if you don t have some fle~ible funding, , . , the task of coordination is 
going to get extraordinarily difficult. ,,
A Funding Source Granting An Organization Some Authority And Flexible Funding For
Promoting SI Should Hold It Accountable For Defining And Measuring Expected Outcomes. 
In retrospect, SI projects of the 1970's and to a lesser extent the 1980' s probably gave too much 
attention to comprehensive planning and not enough to measuring results. In the 1990's, in line 
42 SI projects 
with performance-based approaches being pursued in education and other fields,
should develop performance indicators and use them on an ongoing basis to assess the 
effectiveness of the services being offered to clients and the efficiency and economy with which 
they are being provided. Such a performance assessment is doable 43 and has many potential 
benefits. Among them is the gradual accumulation of a data base that can be used to (1) clarify 
what difference SI makes, (2) help rais~ important questions about the adequacy of established 
administrative and service delivery approaches, and (3) contribute to a broader understanding of 
and support for promising integrative reforms. 
The Cultivation and Maintena.nce of Networks of Individuals Engaged in SI Efforts is Vital to
the Success of These Efforts. 
In 1975, a Rand Corporation report warned, "In the absence of rather decisive DHEW initiatives, 
44 Fifteen years 
services integration will continue to be a marginal and isolated phenomenon. 
later, that warning still deserves serious consideration, SI efforts occur at the periphery of the 
human services system, not at its core. They are a diverse and widely scattered set of initiatives, 
With relatively little expenditure of funds, HHS, other Federal agencies, State and local agencies, 
and others can help connect those involved with these initiatives, They can do this in various 
ways, but especially by serving as a regular convener of governmental officials, private service 
agency officials, foundation representatives, academics, and others associated with SI reforms. 
In so doing, they could be instrumental in disseminating valuable information, stimulating ideas, 
and fostering effective SI strategies for the 1990' III: 
CHAPTER  DEFINITIONS 
SERVICES INTEGRATION 
HEW Secretary Elliot Richardson, in a June 1, 1971, Departmental memorandum entitled 
Services Integration. . .Next Steps: 
Services Integration refers primarily to ways of organizing the delivery of services to 
people at the local level. Services Integration is not a new program to be superimposed 
over existing programs; rather, it is a process aimed at developing an integrated 
framework within which ongoing programs can be rationalized and enriched to do a 
better job of making services available within existing commitments and resources, Its 
objectives must include such things as: (a) the coordinated delivery of services for the 
greatest benefit to people; (b) a holistic approach to the individual and the family unit; (c) 
the provision.of a comprehensive range of services locally; and (d) the rational allocation 
of resources at the local level so as to be responsive to local needs. 
Integration of Human Services in HEW: An 
HEW, Social and Rehabilitation Services, in 
1972: 
Evaluation of Services Integration Projects, 
The linking together by various means of the services of two or more service providers to 
allow treatment of an individual's or family s needs in a more coordinated manner (p. 5). 
William A. Lucas, Karen Heald, and Mary Vogel of the Rand Corporation Census 
, in  The  1975 
A Working Note Preparedfor the Department of Health 
of Local Services Integration Projects: 
Education a~d Welfare December 1975: 
An innovative organizational effort to coordinate or consolidate human services activities 
at the local level in traditional agencies as a means of enhancing the effectiveness, 
efficiency, and/or continuity of comprehensive service delivery (p. 2). 
Coordinate 
Welfare Simplification: Projects to 
United States General Accounting Office, in 
Services for Low- August 1986: 
Income Families, 
The coordination of benefits and/or services to (1) allow access to and use of benefits by 
all clients, (2) improve effectiveness of service delivery, and (3) achieve efficient use of 
human services resources (p. 1).  CHAPTER IV: CHRONOLOGY 
MAJOR FEDERAL SERVICES 
INTEGRATION INITIATIVES 
1971-1976 
SERVICES INTEGRATION TARGETS OF OPPORTUNITY (SITO) RESEARCH 
PROJECTS 
Initiated in June 1972, the SITO projects were supported by funds from the component HEW 
agencies, particularly the Social and Rehabilitative Services. Over the next few years, ' 45 SITO 
projects were funded. Ten of them were technical studies carried out by consulting fmns or 
public interest groups. The others, most of which were funded for three years, were 
comprehensive service delivery efforts carried out by State or local governments or private 
agencies and intended to provide replicable information on how to integrate the delivery of a 
wide range of human services. Among the many SI mechanisms supported were client tracking 
systems, collocated services, case management, and information and referral systems, 
DEPARTMENT OF HUMAN RESOURCES (DHR) PROPOSAL 
The DHR legislative proposal was one of a series introduced in 1971 by the Nixon 
administration for the purpose of consolidating the executive branch of the Federal Government. 
Building on principles of accountability and authority ~et fonh by the Ash Council, the proposal 
called for a substantial strengthening of the Secretary s role as chief executive officer of the 
Department. ' It also called for a strengthening of the role of the Regional Directors and other 
components of the Department. In this regard, it was widely viewed as a reform that would 
facilitate the integration of services. The proposal did receive some congressional consideration 
but was not passed. 
ALLIED SERVICES ACT PROPOSAL 
The Allied Services Act of 1972 was at the core of HEW Secretary Richardson s and the Nixon 
administration s SI agenda, In fact, in 1972 the President referred to it as an important initiative 
that would help individuals "move more rapidly from public dependency toward the dignity of 
being self-sufficient, " As proposed, the legislation would have allowed HEW to make planning 
and implementation grants available to State and local general purpose governments, to waive 
certain Federal requirements that impede SI, and as part of an Allied Services plan to transfer 
funds from one categorical program to another. The proposal was reintroduced to Congress in 
1974 and 1975, but in the face of widespread opposition by the categorical program interests, it 
was never enacted.  THE INTEGRATED PROJECTS FUNDING SYSTEM 
Introduced in the HEW Office of the Comptroller in 1971, this system came to be known as the 
Switching Station," Its mission was to facilitate the funding of integrative social services 
projects calling for funding from multiple HEW funding sources. Applicants would submit a 
consolidated application to the Station, which would then "pull various switches" to expedite the 
review process, It would not have the authority to fund projects on its own; it would serve as an 
expediter. The Station did operate in the mid-1970' s and did help some applicants receive 
Federal funding for broadly based proposals, but, without supporting legislation, it did not have 
much impact on categorical program restrictions. It was disbanded by 1976. 
SI TECHNICAL ASSISTANCE EFFORTS 
Beginning in 1972, the Office of the Secretary and the 10 Offices of the Regional Director were 
engaged in technical assistance efforts intended to f~cilitate the integration of services at State 
and local levels. These effons were directed largely, but not exclusively, to general purpose 
governments. In some places, they involved suppon for the establishment of State umbrell~ 
human services agencies, as was the case in Georgia. In others, they involved help in 
establishing innovative comprehensive projects, such as Connecticut s Project Triage, a 
pioneering effort to integrate the delivery of health and social services for home-bound elderly. 
In still others,they involved suppon for the establishment of broadly based coalitions, such as the 
New England Human Services Coalition. 
THE PARTNERSHIP GRANTS PROGRAM 
This program was initiated in Fiscal Year 1974 as a major part of what had come to be called 
HEW' s "capacity-building" strategy. This strategy sought to help State and local general 
purpose governments to improve their capacity to plan and manage human services. Over a 
period of about three years, the Partnership program provided about $9 million in funding to 84 
different projects. Funded for up to three years, these projects devoted more attention to 
administrative levels than did the SITO projects. However, they also supported various service 
level linkages, such as information and referral systems. 
COMPREHENSIVE HUMAN SERVICES PLANNING AND DELIVERY SYSTEM
(CHSPDS) PROJECTS 
The CHSPDS projects followed the SITO projects. More than the latter, however, they devoted 
considerable attention to planning and management issues and were intended to be a systematic 
set of experiments., The five grantees (in Brockton, Mass.; Jefferson County, Ky.; Ponsmouth 
Va.; Suffolk County, N.Y.; and Taunton; Mass.) were required to participate in a common 
evaluation and to test the implementation of ten management elements, such as cost accounting 
and case management systems. The projects were funded for three years, but because of funding 
constraints there were major reductions .in the final year and the common evaluation was not 
carried out.  PROJECT SHARE 
One of the most enduring initiatives of this era was Project SHARE, a national clearinghouse
initiated by HEW in 1974-75 to help improve the management of human services. In its early
years, Project SHARE concentrated on compiling SI- related literature and on facilitating
widespread access to it. It prepared and distributed abstracts of that literature and, upon request
conducted searches of it. In addition, it commissioned, published, and distributed monographs
addressing key SI issues. In subsequent years, the clearinghouse has continued to receive HHS
support, but at a lower level and with more of a categorical focus.
TITLE XX OF THE SOCIAL SECURITY ACT
Enacted in 1975, Title XX is a social services block grant. It replaced the social service funding
provided to the States under Titles IV-A and VI of the Social Security Act. Under Title XX
Congress niaintained the $25 billion funding ceiling it had previously established under Title
IV-A. However, it gave States much more flexibility in determining how social services dollars
would be spent. With Title XX funds, they could engage in comprehensive social service
planning and develop a service program that responds, in an integrated fashion, to the particular
needs of its citizens. The program had to be directed to six broadly stated program goals
established by the legislation.
1977-1990
ACCESS SERVICES PROGRAM PROPOSAL
This was a legislative proposal developed by the Office- of Human Development Services in 
October 1977. It called for amending Title XX to make up to $50 million available annually to 
offer incentives to the States "to develop comprehensive multiprogram access projects for the 
purpose of improving accessibility to human services by individuals who need them." Access 
services were defined to include information and referral, transportation, outreach, and other 
such services that would help individuals use available services. The proposal was never passed 
by the Congress. 
NATIONAL NETWORK FOR COORDINATING HUMAN SERVICES
The National Network was funded by the Office of Human Development Services (OHDS)
through a cooperative agreement with a private firm. Through the Network, OHDS sought to
develop and maintain linkages between individuals and organizations interested "in coordinating
services that cross categorical boundaries, gov~rnmental jurisdictions, and the public and private
sectors." In 1980 and 1981, the Network facilitated such linkages and disseminated information
by holding two national conferences and by developing and distributing written and audiovisual
materials, BLOCK GRANT PROGRAMS 
In the Omnibus Budget Reconciliation Act of 1981 , Congress consolidated about 30 separate 
categorical programs into seven block grants: Preventive Health Services; Alcohol, Drug Abuse 
and Mental Health; Primary Care; Maternal and Child Health; Community Services; Social 
Services; and Low Income Energy Assistance. The combined programs were funded at 75 to 90 
percent of the 1981 func:!ing levels, but under them, the States had fewer reporting 
responsibilities to the Federal Government and greater discretion in how they could spend the 
funds. With less "red tape" and more flexibility, the opportunities for integrating services were 
enhanced. 
SERVICES INTEGRATION PILOT PROJECTS: 
In the Deficit Reduction Act of 1984, Congress authorized Federal funding for SI pilot projects 
that would help individuals and familids achieve social and economic self-sufficiency, In May 
1985, OHDS awarded demonstration grants to the States of Arizona, Maine, Oklahoma, South 
Carolina, and Florida. Each State was responsible for testing a common set of SI mechanisms, 
such as common resource directories, unified budgeting and accounting systems, uniform 
application and eligibility procedures, and standardized procedures for purchase of services, 
The States received grants in subsequent years as well and with them were able to establish a 
number of important linkages. However, a common evaluation that was planned did not 
materialize because of financial problems experienced by the contractor that was selected to 
perform the evaluation. 
INTERAGENCY LOW-INCOME OPPORTUNITY ADVISORY BOARD 
The Board was established by executive order on July 20, 1987, to promote the coordination of 
public assistance programs and policies. Located in the White House, the Board served in 1987 
and 1988 as a focal point for welfare reform demonstration proposals, It worked with States in 
facilitating such proposals and with Federal departments in reviewing and approving them. 
Among 26 proposals submitted to the Board by the States, 16 were approved. The 
demonstrations addressed coor~nation in various ways, but stressed particular programmatic 
elements, such as transition bene~its for welfare recipients who obtained employment.  CHAPTER V: FINDINGS FROM

SELECTED NATIONAL STUDIES ON

SERVICES INTEGRATION

1972 
s. Department of Health, Education, and Welfare, Social and Rehabilitation Services, 
Integration of Human Services in HEW: An Evaluation of Services Integration Projects 
1972. 
Volume  I, 
This study was commissioned to understand more clearly the nature and progress 
Background: 
of ongoing efforts in services integration and to identify possible Federal actions most conducive 
to support of the efforts. Thiny case studies were developed based on document reviews and 
interviews with the major participants and observers. of the projects ' history. These case studies 
provided the basic information for conducting the study analysis. 
Major Findings: 
Services integration is not extensive. Even in the projects identified as successful 
none had fully developed a majority of the service linkages being reviewed, 
Services integration is an evolutionary process. It takes time to organize and 
implement, time to attain legitimacy in the eyes of service providers, and time for 
participating agencies to develop working relationships. 
Services integration is facilitated and inhibited by numerous factors. But no single 
factor is instrumental in benefiting or impeding a majority of the projects. 
Services integration results in improved accessibility, continuity, and efficiency of 
client services. 
There is no one best services integration method for providing client services. 
Development of different linkages requires differing resources and incentives, and 
, varying periods of time. 
Clients can be an important integrative force. 
S. Department of Health, Education, and Welfare, Report on the Task Force on 
Administrative and Organizational Constraints to  June 1972. 
Services Integration,  The purpose of this report was to examine the administrative and organizational 
Background: 
practices that impede the integration of services. It was based upon four site team reports and 
drew upon a number of papers. 
Major Findings:
Major barriers to services integration arise more from the attitudes and behavior of 
the people involved than from organizational arrangements, admini~trative practices 
and regulations. 
DHEW is organized along professional lines for historic, legislative, and educational 
reasons, This has resulted in few human services generalists who could cut across 
program and professional lines to deal with a broad range of human needs, 
The sheer size of the DHEW system and its State counterparts results in unfortunate 
competition among groups at the local level who should in fact be cooperating. 
Within the DHEW maze it is difficult to find that responsible party who can make a 
decision or hold others accountable. 
DHEW erects barriers to services integration by its categorical funding nature, the 
variation in program decentralization, the lack of infonnation, the nature of technical 
assistance, and the lack of regional authority. All of these factors work against a 
more responsive and efficient Federal system. 
1974 
Human Services Integration: State Functions in 
The Council of State Governments, 
1974. 
Implementation, 
This study sought to gather information on consolidated human resources 
Background: 
agencies, the perceptions of agency officials on the nature of services integration, and their 
priorities in achieving it. The information was based on a 50 State mail survey and on-site visits 
to 20 States. 
Major Findings:
Human services integration is not a top priority item in many States. 
Services integration is a panicularly difficult concept to implement in large urban 
States because of the magnitude of social problems and the multitude of public and 
private agencies involved.  Many States have established comprehensive human resource agencies, Such a move 
basically leads to efforts to coordinate programs and administrative services, but not 
necessarily to services integration, 
It is too soon to determine whether a comprehensive human resource agency is a 
vehicle that can successfully accomplish integration of human services. 
States' political and bureaucratic issues have been important barriers in attempts to 
integrate services. Other barriers have resulted from Federal grants and legislation 
and from regulations administering the grants. 
Title IV-A of the Social Security Act, authorizing Federal funds for State and local 
social services programs, can be instrumental in promoting services integration, 
1975, 
An Evaluation Prepared for the 
Douglas Henton,  The Feasibility of Services Integration: 
HEW Interagency Services Integration R&D Task Force  March 1975. 
This study analyzed 34 demonstration projects and 6 case studies in an attempt to 
Background: 
provide information useful for future policymaking. Its purpose was to determine those 
conditions in which services integration appears feasible and the factors influencing the adoption 
of service linkages in the demonstration projects. 
Major Findings: 
Services integration does not appear to be an organizational strategy that can be 
applied with equal success in every locality. Services integration appears to be 
feasible only in particular environments employing specific strategies. 
Services integration should not be promoted by the Federal Government as the most 
appropriate strategy for every community. Linkages have been adopted more readily 
in "stable rural environments" than in "turbulent urban environments. 
In some communities the costs of services integration outweigh any benefits 
produced, 
Services integration must be approached with realistic expectations. Attempts 
level or comprehensive human services planning must be 
large-scale State-
approached with extreme caution. 
Human services organizational networks must be adapted to local environments and 
no one structure can be implemented in every environment.  William A. Lucas, Karen Heald, and Mary Vogel, Rand Corporation, prepared for the U. 
Census of Local Services
Department of Health, Education, and Welfare, 
 The  1975 
Integration  December 1975. 
The purpose of this research effort was to examine issues related to how one
Background: 
would go about integrating services once it was decided that services integration was a desirable
goal. A research census of 70 SITO (DHEW's Services Integration Targets of Opportunity
program) and non-SITO sites identified the scope and approaches used for services integration.
Major Findings:
In the absence of decisive DHEW initiatives, services integration will continue to be a
marginal and isolated phenomenon.
If DHEW wishes to see a serious reorganization or changes in traditional philosophy,
it must be prepared to provide extensive funds and change DREW regulations to
encourage such activities.
IfDHEW continues with its service integration effons, it must recognize that (1)
research and development funds are vital, (2) categorical programs may pick up many
of the better projects, (3) extensive planning models are of varying use,- but not 
sufficient value to be required, and (4) projects with continuing interactions among
service staffs may progress better than other projects. 
1976
Rolesfor General Purpose Government in  Project
Sidney L. Gardner,  Services Integration, 
SHARE, Human Services Monograph Series, No. 2, August 1976.
The focus of this study was to look at HEW's effons to expand the capacity of
Background: 
State and local general purpose executives to plan and manage categorical human services
programs and HEW's effons to integrate such programs through a variety of demonstration
projects.
Major Findings:
Projects seeking institutional change cannot survive if constantly concerned with
resource mobilization rather than program operation. Federal funding cycles and 
limited State and local budgets contribute significantly to this effect.
Effective project leadership is a sine qua non for capacity-building.
Consensus building is imponant in ensuring that services integration is an ongoing
capacity, Federal and State capacity-building agendas often diverge under different pressures 
and incentive systems, 
Gerald T. Horton, Victoria N. E. Carr, and George J. Corcoran  Illustrating Services 
Integrationfrom Categorical  Project SHARE, Human Services Monograph Series, 
Bases, 
No. 3, 1976. 
This repon focuses on one method of services integration, starting with a 
Background: 
categorical funding and program base which was expanded to integrate complementary services 
and resources into a comprehensive service package. Four projects were examined in detail. 
Major Findings: 
Funding is a major determinant in services integration. The amount and type 
funding shapes the initial implementation and integration of services. 
A strong project leader capable of mobilizing resources, merging conflicting opinions 
or groups, planning effectively, and relating to a broad section of the community and 
providers facilitates services integration. 
Community receptivity to the need for services and the desire to provide effective 
delivery are necessary. 
An administrative structure must be in place to allow for planning and implementing 
of services integration. 
Staffs ' desire to increase service delivery effectiveness affects services integration. 
Long-term planning must be implemented and include project goals and purpose, 
methods to integrate service delivery, and current and future funding sources, 
1977 
DeWitt John, prepared for the Center for Social Research and Development, Denver 
Research Institute, University of Denver, Denver Managing the Human Service 
, Colo., 
System  : What  Project SHARE, Human 
Have We Learnedfrom Services Integration?, 
Services Monograph Series, No.  , August 1977. 
This study reviews and assesses the final reports and evaluation of 20 SITO 
Background: 
(DHEW' s Services Integration Targets of Opportunity program) projects, paying particular 
attention to the impact of interagency linkages on efficiency, effectiveness, and accountability.  Major Findings: 
The fiscal squeeze faced by State and local human service agencies, and Federal 
State, and institutional barriers led to few successful fiscal linkages being tried or 
implemented successfully. 
Collocating provider services to enhance personnel linkages had mixed results. Some 
projects did experience an increase in savings, service accessibility, communication 
and staff sharing. 
Agency turf issues can adversely affect efforts to establish planning and programming 
linkages. 
Multiagency client information systems resulted in less efficient administrative 
linkages and did not provide information-necessary for determining eligibility. 
Core service linkages can substantially increase client service accessibility, may 
increase service system responsiveness to clients, and may foster strong informal 
relationships between agencies, 
There is little evidence to suggest that efforts to increase case coordination linkages 
are successful. 
1978 
Rj Associates and SRI International for the U.S. Department of Health, Education and 
Welfare, Office of the Assistant Secretary for Planning and Evaluation  Assessing the 
DREW Partnership Grants Program: A Study of State and Local Government Capacity 
Final Report, February 1978. 
Building, 
This report is an assessment of the Partnership Grants Program initiated by the 
Background: 
Department of Health, Education and Welfare in 1974. Its purpose was to learn more about the 
effectiveness of differing modes Of human services planning, management, and delivery 
techniques being tested in 20 demonstration projects. 
Major Findings: 
The political environment of a particular jurisdictional setting was the most important 
factor in establishing parameters as to what could be accomplished and the degree of 
difficulty a project was likely to experience in implementing a strategy to achieve its 
objectives,  The active support of chief officials is essential to the successful implementation of a 
major new organizational or process reform within the human services system; 
without such support reforms are unlikely to be successful. 
Designation of the organizational location for human services must rest with the chief 
elected officials and/or their immediate staff. 
The optimum strategy to achieve human services reform involves a balance between 
the political process of generating and maintaining consensus among decision makers 
and the technical activity of developing research products to facilitate the political 
process. 
1980 
Pat G. McGinnis and Fredrick M. Bohen, U.S. Department of Health and Human 
Executive Summary, 
Services, Office of the Secretary,  Eligibility Simplification Project, 
September 9, 1980.
The study looked at approaches to eligibility simplification for the seven core 
Background: 
assistance programs that comprise 10 percent of the Federal budget. Analyzed were Federal 
program requirements affecting eligibility and procedures. 
Major Findings: 
Existing programs fail to meet the needs of Citizens in an efficient and responsive 
manner. 
There is no agreement on income and asset definitions by the different programs, 
The programs have different approaches to gathering client financial data, verifying 
financial data, and determining eligibility. 
Nonfinancial conditions of eligibility differ among the programs. 
1983 
S. Department of Health and Human Services, Omce of Human Development Services, 
A Review of the Conceptual Foundations and Current 
Office of Program Development, 
January 13, 1983. 
Status of Services Integration, 
This paper traces the development of human services integration from the early 
Background: 
1970' s to 1983 and highlights key observations that have emerged from the work. Offered are 
suggestions to facilitate effective services planning and delivery along with examples from  present and planned projects and demonstrations that have explored or will address selected
approaches to achieve services integration,
Major Findings:
Although integrated service delivery does not necessarily reduce the cost of services,
it does result in more complete assessment of client needs and the development of
more comprehensive service programs addressing those needs.
The success of services integration efforfs depends heavily on the commitment of
managers and key staff of participating agencies,
A taxonomy of services and a comprehensive resources directory are vital to
integrated program and case planning.
Collocation alone will not ensure interprogram coordination.
Lack of timely, comprehensive, and relevant data often serves as a barrier to service
integration.
1987
Welfare Simplific(l.tion: States' Views on
United States General Accounting Office, 
Coordinating Services for Low- GAO/HRD-87-110FS, July 1987.

Income Families, 
This report is GAG's fourth in response to congressional committees' requests for
Background: 
information on services integration. It summarizes responses by 49 States to a GAO
questionnaire. The questionnaire focused on families eligible to receive benefits under six
low-income assistance programs and addresses collocation of services, coapplication for
services, coeligibility and determination for services, and the use of a single case manager for
servIces.
Major Findings:
For the four types of integration examined, 23 States have integrated their service
delivery units for the three major benefit programs-Aid to Families with Dependent
Children, Medicaid for the Categorically Needy, and Food Stamps,
Thirty States have started at least one services integration project since October 1
1983.
Among the most frequent obstacles to services integration were the multiple
regulations and different financial eligibility requirements used by various programs. ,----"'---'" -
Few States indicated that the Department of Agriculture or the Department of Health 
and Human Services had encouraged services integration to any great extent, 
The three reasons most often cited for eligible families not receiving benefits were (1) 
transportation difficulties, (2) lack of outreach services, and (3) insufficient funds for 
cenain programs, especially Section 8 housing.  ""'--"" -,.. ,  '. ...,---_..'--_..'
APPENDIX A
ENDNOTES
We reviewed many HEW /HHS funded reports addressing the results of SI efforts; all the 
relevant reports of Project SHARE, a national clearinghouse funded by HEW in the 
mid-1970's to improve the management of human services; many articles in journals 
Public Administration Review  New England Journal of Human Services 
. such as th~  the 
and various internal documents associated with departmental 
and Social Services Review; 
task forces and reviews over the years. 
See, for instance, Sidney L. Gardner Roles for General Purpose Governments in
Project SHARE, Human Services Monograph Series, No.  , August
Services Integration, 
1976, p. 5.
Introduction  Human Services Integration: Special Publication  American Society 
" in 
for Public Administration, March 1974, pp. 2-
See Donald A. Schon  (New York: W.W. Nonon & Co., 1973), 
Beyond the Stable State 
pp. 63-64. 
See Mark R. Yessian and Rosalie H. Lang, "The Quest for Human Services Integration as
Reflected in HEW  Journal of Health and  3, no, 4
Hum,an Resources Administration 
(May 1981): pp. 517-539; and Walter Trattner From Poor Law to Welfare State: A
(New York: the Free Press, 1974).
History of Social Welfare in America 
See chapter IV for a chronology of major SI initiatives undenaken by HEW/HHS in the 
1970' s and 1980' 
In this context, the Nixon adrmnistration introduced the Family Assistance Plan
legislative proposal. Had it passed Congress, it would have made income maintenance
for low-income families a Federal responsibility. See Douglas Henton  The Feasibility of
Services Integration: An Evaluation Prepared for the HEW Interagency Services
March 1975, p. 5.
Integration R  D Task Force, 
See Yes sian and Lang, pp. 519-527. Much of Richardson s SI agenda was based on a
February 1971 report prepared under the direction of Deputy Assistant SecretarySidney
Services Integration in HEW: An Initial Report"
L. Gardner and entitled 
General purpose governments are regarded as the sphere of elected officials having broad
responsibility for governance. Although this encompasses the legislative as well as the
executive branch, the HEW capacity-building agenda dealt primarily with the latter-
particular with the immediate offices of the chief executive or with the umbrella human
services agencies reporting to the elected chief executive. .. "'-'-"-'~..,, .."  , "  .. --------, ,-_..,  , p.
10,	 The other programs specified are public health, mental health, mental retardation, adult 
corrections, youth institutions, vocational rehabilitation, and employment services, See 
Keon S. Chi  What Has Happened to the Comprehensive Human Services Agency?" 
7, no. 3 (1987): 24-30, 
New England Journal of Human Services 
11.	 Many reports have been written on the Florida reorganization and its implementation, 
See Laurence E. Lynn, Jr.  Organizing Human Services in Florida,  3, nos, 
Evaluation 
2 (1976): 58-97; National Academy of Public Administration Reorganization in 
Florida: How Is Services Integration ,Working?,  Washington, D.  , September 1977; 
After a Decade: A Progress Report on 
and National Academy of Public Administration, 
the Organization and Management of the Florida State Department of Health and 
Rehabilitative Services,  April 1986. 
12.  See Yessian and Lang, pp. 534-535. 
13.	 Robert A. Weyer, "Block Grants at the Local Level: New Jersey and the New 
Federalism 
New England Journal of Human Services,  no. 4 (1985): 17. 
14.  In 1987, as in 1976, there were 26 State umbrella human services agencies. See Chi 
29. 
15,	 The lesser visibility in the 1980' s is quite apparent in the decrease in the literature on the 
topic. In a SI bibliography prepared by the General Accounting Office in 1986, there 
were 120 citations involving publications issueq between 1972 and 1979 and 40 for those 
issued between 1980 and 1986. See GAD,  Welfare Simplification: Projects to 
Coordinate Services to Low- GAOIHRD-86-124FS, August 1986, pp. 
Income Families, 
50-67. A subsequent GAO repon, based on a survey of the States, indicated that 30 
States started at least one SI demonstration project since October 1, 1983. See GAO, 
Welfare Simplification: States' Views on Coordinating Services for Low-Income 
Families,  GAOIHRD-87-11OFS, July 1987, pp. 21-22. 
16,	 This is a development that Alfred 1. Kahn and Sheila B. Kammerman noted as far back as 
the late 1970's, when they commented: "a number of categorical entities in HEW 
responding to legislative mandates, constituency pressures, and professional initiatives 
have moved towards creating integrative service delivery systems of a comprehensive 
Prime illustrations in some States are rehabilitation 
son  for these special categories. 
services, services for the aged, community mental health programs, child and family 
welfare systems." See "The Course of Personal Social Services, 
Public Welfare 
(Summer 1978. 
17.	 These positive impacts are documented in many national and local reports. See 
especially, DeWitt John  Managing the Human Service "System  : What Have We 
Project SHARE, Human Services Monograph Series 
Learnedfrom Service Integration?, 
No, 4, August 1977; Gerald T. Horton, Victoria N.E, Carr, and George J. Corcoran 
Project SHARE, Human 
Illustrating Services Integration from Categorical Bases,  , "  .. ",--""".,."  ".... .._-,--.. ,_....,
Services Monograph Series, No, 3, 1976; and Michael E. Fishman and James V. Dolson 
The Evolution of Human Services Integration: A Federal Perspective," an unpublished 
paper prepared in 1987 for a conference sponsored by the Human Services section of the
American Society for Public Administration and entitled "Whatever Happened to the
Umbrella Human Services Agency?"
18,(cid:1) The Community Life Association:  1972-1975, Final Evaluation Report, January 
From 
1976, p. 63. 
19,  Human Services Integration: Special Publication.
See 
20,(cid:1) A specific illustration of this kind is the highly fragmented system for delivering prenatal
services to low-income pregnant women in Boston (and other cities). See Office 
OAI-0l-88-01420,
Inspector General,  Evaluation of the Boston Healthy Baby Program, 
July 1989.
21.  See GAO,  Welfare Simplification: States' Views on Coordinating Services for 
Low- pp. 25-38. 
Income Families, 
22,(cid:1) In particularly candid comments, Sidney Gardner, director of the Community Life 
Association s SI project, noted the following at a May 6-7, 1976, meeting of the New 
England Human Services Coalition: "When we got down to the final decision about 
pick-up, the merits of our program were almost fully irrelevant. To the extent they even 
made conscious decisions, the city and state made their decisions based upon no new 
programs and no new funding, no new outsider' ,units arid no new non-profit providers. 
23.  Department of Health, Education Report of the Task Force on
, and Welfare, 
June 1972, p, 17, 
Administrative and Organizational Constraints to Services Integration, 
24.  See John  Managing the Human Services ((System,  p. 68. 
25,  See Schon Beyond the Stable State.
26,  J. Laski  The Limitations of the Expert,  Harper December 1930, p. 106. 
s, 
27.(cid:1) Sidney L. Gardner  Department of
Services Integration in HEW: An Initial Report, 
Health, Education, and Welfare, February 26, 1971, p. 5.
28,  The relevance of these integration roles is addressed in many reports. See especially,
Gardner Roles
Horton et aI.,  Illustrating Services Integration from Categorical Bases; 
for General Purpose  R. J. Associates and SRI 
Governments in Services Integration; 
International  Assessing the HEW Partnership Grants Program: A Study of State and 
Arlington, Va., and Menlo Park, Calf" 1978; and
Local Government Capacity Building, 
Dimensions of Services Integration: Service
Robert Agranoff and Alex Pattakos, 
Project
Delivery, Program Linkages, Policy Management, Organizational Structure, 
SHARE, Human Services Monograph Series, No. 13, April 1979. .---.',".,.. 
..- "0-

29.  This may be a reflection of what Peter Drucker describes as a new pluralism in society 
and a decreasing capacity of government to function as an integrator of interests. See 
Peter F. Drucker  (New York: Harper and Row, 1989), 
The New Realities 
30,  For elaboration on some of the critical distinctions among general administration 
program administration, and service delivery spheres of operation, see Mark R. Yessian 
Delivering Services in a Rapidly Changing Public Sector  American Behavioral 
, no. 6, 1978, pp. 829-857. See also Mark R. Yessian, "The Generalist 
Scientist 
Perspective in the HEW Bureaucracy: An Account fmm the Field,  Public 
March/April 1980.

Administration Review, 
31.  Human Services Integration: State 
See, for example, Council of State Governments, 
Lexington, Ky., 1974, p. 4. 
Functions In Implementation, 
32,  See ibid, and the Department of Health, Education, and Welfare, Office of the Assistant 
Secretary for Planning and Evaluation, "Services Integration and the Department of 
Health, Education, and Welfare," January 1977. 
33,  For instance, the supponers of the Connecticut Council on Human Services, an umbrella 
State human services agency found that in the face of opposition by programmatic 
interests, there was little political support for integrative approaches that could not 
deliver short-term solutions to complex problems. See Rosalie H. Lang, "The Council on 
Human Services: A Case Study in the Failure' ofHuman Service Coordination, " paper 
deliver~d at the May 6-7, 1976, meeting of the New England Human Services Coalition, 
34,  See, for instance, Fishman and Dolson, "The Evolution of Human Services Integration: 
A Federal Perspective,
" p. 7. 
35,  See, for example, John Managing the Human Services tlSystem,  p. 68; HEW, "Services 
Integration and the Department of Health, Education, and Welfare," 1977; and 
Department of Health and Human Services, Office of Human Development Services, " 
Review of the Conceptual Foundations and Current Status of Services Integration 
January 13, 1983,
36,  (Managing the Human Services ((System,  p, 69) 
With respect to the SITO projects, John 
indicates that the evidence from them is "fragmentary and difficult to assess," largely 
because of inconsistent definitions and limited quantitative measurements of impact. 
must also be noted that other conceptualizations and evaluations of the projects suffered 
from an overly rigid framework in which SI was reviewed essentially as an 
organizational design and systems engineering problem." See Yes sian and Lang, p, 522, 
The CHSPDS and SIPP effons sought to produce more definitive results than the SITO 
projects by establishing common frameworks and definitions at the start. Yet,
evaluations planned for the two effons did not occur. In the case of the CHSPDS  , "'. ---""..,. 
projects, this was because the funding did not become available; in the case of the SIPP 
projects, it was because the selected contractor went bankrupt. 
37,  In this regard, the following excerpt from the final evaluation report of the Community 
Life Association SITO project provides food for thought: 
It can be argued that any system has only limited toleration of innovation; yet 
CLA sought innovation across the entire human services system, from top to 
though unanswered--question to ask whether more 
bottom. But it is a fair-
modest, clearly focused goals of reform at fewer points in the human services 
system would have had some greater results. (p. 60) 
38,  Here, again, a valuable lesson can be learned from prior efforts. Years ago, the project 
report prepared on the Jonesboro, Arkansas, SITO project offered the following 
conclusion based on that project s experiences: 
If Congress or the Arkansas General Assembly provides funds for the Blind, 
they expect funds to be spent for that group and not an abstract administrative 
It is our 
concept such as core administration or generic case management. 
opinion that so long as lobby groups influence legislation, and funds are noted 
, categorically, services will be administered and delivered categorically. 
See John  Managing the Human Service "System,  pp. 15-16. 
39.  See Drucker  p: 66. 
The New Realities, 
40,  HEW Secretary Elliot Richardson emphasized this point in the June 1, 1971 
memorandum that outlined his SI agenda. In that memorandum, he indicated that in 
itself coordination among service providers was "not likely to be fully effective. " He 
added that "some process should be set in motion that will lead toward a degree of 
centralized management, with a proportional curtailment of sovereignty by each of the 
participating agencies. 
.1976. 
41.  Sidney L. Gardner, remarks before the New England Human Services Coalition 
conference, May 6-
42.  Of panicular note is that the White House and National Governors ' Association have 
established a panel to gauge the nation s progress toward six mutually agreed upon 
education goals, One of the immediate tasks of the panel is to select precise measures to 
assess progress in reaching these goals. 
43,  See, for example, R. Miller et ai  Developing Client Outcome Monitoring Systems: A 
Guidefor State and Local Social Service  (Washington, D. c.: The Urban 
Agencies 
); Reginald Caner  SAGE Human Services 
Institute, (u,  The Accountable Agency, 
Guides, vol. 34 Sage Publications, (Beverly Hills, Calf.; 1983); and Harry B. Hatty,  Program Evaluation and Client Outcome Monitoring for State and Local Human Service
Agencies,  New England Journal of Human Services  Winter i985, pp, 34-41.
Agencies, 
44.(cid:1) William A. Lucas, Karen Heald, and Mary Vogel  Census of Local Services 
The  1975 
Integration: A Working Note Prepared for the Department of Health, Education, and 
Rand Corporation, WN-9289-HEW, December 1975, p. 45. 
Welfare,