Bridges Out of Poverty

Image Bridges Out of Poverty

A History of the Arlington Bridges Out of Poverty Work 2016-2023

This impactful initiative began in 2016 when Arlington County Department of Human Services (DHS) identified the potential of using the Bridges Out of Poverty (BOP) Framework to be more effective in serving households facing generational poverty and multiple challenges. DHS asked the Arlington Community Foundation (ACF) to convene the local safety net nonprofits into partnership to further explore implementing the framework in Arlington. Over the course of the next 7 years, hundreds of staff from DHS, ACF and Arlington nonprofits participated in the systems reform work and in pilot testing the system improvements designed to make our local safety net system more effective with fewer bureaucratic barriers. Key aspects of the years of work are described here.

Learning as a community

From 2016-18, ACF and DHS leadership convened 100 senior managers and 200+ front line staff from 20 Arlington nonprofits and a wide array of DHS programs in housing, employment, public assistance, health, child and family services, and behavioral health for a series of intensive trainings with Bridges Out of Poverty consultant Jodi Pfarr. While our local initiative did not fully embrace certain aspects of the BOP curriculum concerning stereotypes of “poverty culture”; we did embrace the BOP principles related to our systems change agenda.

The Bridges partners also embraced the US Partnership on Mobility from Poverty’s emphasis on belonging to community and having personal power over one’s life as requisites to mobility, along with increasing one’s financial assets.

The partners also agreed to emphasize these key elements as our public-private collaborative worked on a new way of doing business with people in poverty. We heard from people regarding their own experiences with the system and their coping mechanisms and social networks via 20 one-on-one interviews and multiple focus groups held by some of the nonprofits with their clients. 

Through 2019, a core group of 75 senior and front line staff from all of the organizations continued to hold quarterly convenings and dozens of ad hoc work groups to improve how we foster mobility through systems and policy change.

Participating Organizations

AHC Inc. | Arlington Community Foundation | Arlington County Aging and Disability Services | Arlington County Behavioral Health Services | Arlington County Community Assistance Bureau | Arlington County Community Health Services | Arlington County Housing Assistance Bureau | Arlington County Public Assistance Bureau | Arl. Education and Employment Program (REEP) | Arlington Employment Center | Arlington Food Assistance Center | Arlington Free Clinic | Arlington Partnership for Affordable Housing | Arlington Pediatric Center | Arlington Public Schools Welcome Center | Arlington Thrive | Bridges to Independence | Bu-Gata | Carlin Springs Community School | Doorways | Just Neighbors | Legal Aid Justice Center | Neighborhood Health | Northern Virginia Family Service | OAR | Path Forward | Shirlington Employment and Education Ctr. (SEEC)

Breaking down bureaucracy within individual organizations and across the public-private system

During the early years (2016-17), staff from each participating organization, with input from clients, mapped their own “client life cycle”. This involved examining the steps and barriers faced by clients trying to make an appointment, go through intake, show eligibility, get referrals, etc. Then, each organization explored ways to streamline their processes. Practices that are now taken for granted were put in place for the first time in many of the organizations. For example: Just Neighbors switched its intake process to be over the phone or online, so clients didn’t have to take off from work to get their case started. Several organizations created children’s areas for children who accompany their parents in their appointments.

DHS started same day access for walk-in clients of Arlington DHS Arlington Behavioral Health’s Emergency Services and Jail Diversion program. Arlington Free Clinic streamlined and later eliminated its lottery system to improve access for new patients and integrated their pharmacy services into the medical visit rather than having patients return another day for a prescription.

Next, we shifted from individual organizational change to transforming service systems. The BOP partners mapped a detailed inventory of available community resources that provide basic needs (housing, food, health), as well as social and spiritual supports, employment, financial literacy and assets and educational advancement. We identified that we had too few programs and organizations that build these resources and skills in partnership with clients as opposed to delivering them as a service. We saw that we did not have enough opportunities for people isolated by poverty to belong and be involved in our community. We needed better ways to reach undocumented residents fearful of accessing services and being known to the system.

We also identified bottlenecks and redundancies across the system that waste people’s time and cause them to give up hope. This work involved difficult conversations, radical interpersonal and inter-agency honesty, and openness to new ways of doing business and reducing unnecessary “agency time”. 

As a result of this work, in 2018, we launched several new systems tools and processes:

  • a single HIPAA-compliant multi-party release form to responsibly exchange client information across DHS, other County departments, the hospital, Arlington Public Schools and the nonprofit safety net. The shared form is currently in use by 38 community organizations. This single form relieves the burden of filling out many different release forms by people seeking a variety of services.  It is recognized across the country as unique, impactful and time saving, and dispelled the myth that it couldn’t be done.
  • a 24-hour response email address for inquiries from community service providers needing to identify County points of contact working with their shared clients.
  • a Social Services Wiki where both County and nonprofit service providers can find comprehensive up-to-date information on available public and private resources and eligibility requirements. 

As another example of streamlining systems, Arlington DHS partnered with the Arlington Public Schools Welcome Center so that children newly arrived to the US could get same-day vaccinations and physicals while being registered for school.

200 Bridges: a household level pilot testing the system improvements

In fall 2018, the partners launched a pilot called 200 Bridges to test our public-private safety net reforms on Arlington households who cycle in and out of crisis and could benefit from a more holistic, relational approach to the barriers that keep them from moving forward. It was envisioned that: “families who choose to participate in this pilot will be less burdened by bureaucracy as they work to improve their mobility. They can expect to experience a tangible difference in their interactions with the system and all its public and nonprofit components. They will work with a primary contact with whom they have a trusting relationship and will access the services they need in a more streamlined process.”

Urban Institute assisted with the design of the pilot and Aspen Institute’s Ascend Two-Gen outcomes were adopted. Over the course of the next 4 years, 100 households participated.

The 200 Bridges pilot used a two-generation approach with parents and their children to build opportunities for stable housing and child care, jobs with better wages, health care, and educational advancement. This united effort involved unprecedented collaboration across the County, nonprofit system, and families.

The boots on the ground for the 200 Bridges pilot were 22 trained nonprofit and DHS case workers embedded in locations across the community (health clinics, affordable housing properties, family shelters, and Arlington DHS). Supporting the case workers who were the single points of contacts were monthly case review teams of 8-10 professionals each with expertise in key domains such as housing, health, employment, education, and child care. During the meetings, review team members from DHS and the partner nonprofits used their networks and expertise to provide action-oriented suggestions, real-time information on client benefits applications status, and warm handoffs to other resources rather than a list of phone numbers.

The BOP partners created an adapted version of the Arizona Family Self-Sufficiency Matrix to track adults’ and children’s progress as they moved across a continuum from crisis to stability, to building capacity, to empowered, to thriving across 18 different domains. 40 County and nonprofit staff were trained to use this tool as a way to engage families in their own goal setting and progress across these domains. In 2019, the points of contact and case reviewers were trained in EMPath Mobility Mentoring to help the households break down their goals into actionable steps and recognize success when they do so.

ACF and Urban Institute had hoped to work with DHS and the nonprofits to explore community-level benchmarks that reflect our desire for all Arlingtonians to reach their full potential. However, there was more foundational work that needed to be laid across the community organizations to get to this point. The County did adopt an Equity Resolution in 2018 committing to “all populations having access to community conditions and opportunities needed to reach their full potential and to experience optimal well-being.” There are also key disaggregated data points on social determinants of health now available. The resolution and data are a result of the County’s Destination 2027 initiative, of which ACF and many of the community nonprofits were a part. However, aspirational indices are still not developed.

Evaluation outcomes of the 200 Bridges pilot

Four annual evaluations were conducted comparing household outcomes after 6, 12 and 18 months in the pilot. Prior to the pandemic, there were improvements in all 17 domains after 6 months in the pilot, and even more improvement after 12 months, especially in housing, employment, child care and children’s education, English and technology proficiency, community involvement, and mobility. Households’ increases in access to health insurance and health care have been especially significant across all 4 evaluation years. There were sobering findings as well, showing the drastic living wage gap among Arlington’s low income workers and the effects of the pandemic:

  • While income increased significantly over time, the average income for participating households still remained very low after 12 months at just over $25,000.
  • Focusing in on impacts of the first six months of the COVID pandemic, the majority of families declined from pre-COVID gains in all domains.
  • Large declines due to COVID were seen in employment, income, child care, child education, mobility, community involvement, health care access, parenting and mental health.
  • However, some families actually improved in certain domains during COVID, especially in housing (eviction moratorium), food security (expanded food distributions and SNAP eligibility), family and social relations, adult education, English proficiency, safety, and disability services.

Today, even though the pandemic emergency is over, ongoing mental health and employment/income challenges remain difficult.

200 Bridges also continued to expose new ways to improve the local safety net system. For example, based on the large number of undocumented participants and the ongoing fears associated with public charge rulings, the County contracted with Legal Aid Justice Center to provide free immigration status assessments for all participants for whom this is an issue. For those who have a path to citizenship, Just Neighbors takes the case.

Another example was the elimination by Arlington DHS of the requirement for clients to seek child support in order to be eligible for a housing grant. Fear of engaging a former partner for child support enforcement has been a barrier preventing too many households from obtaining housing supports for which they were otherwise eligible.

Winding down 200 Bridges

There was a marked drop in referrals to 200 Bridges during the pandemic, which was understandable due to how overwhelmed households and case workers were in dealing with the health and economic crises. In addition, pandemic-era relief programs and lowered barriers to emergency resources diluted the need for individual review teams.  Even after the pandemic intensity lessened, however, referrals to the teams remained very low. The 200 Bridges Leadership team sought input from the points of contact (case workers) to discern what was behind the ongoing absence of referrals.

Two main themes emerged. With the roll-back of pandemic-related economic supports and extra services for households, low income residents and their case workers are as overwhelmed as they were during the pandemic emergency. The current volume and urgency of some clients’ needs can’t wait for a monthly meeting. On the positive side, many case workers stated they no longer need to come to the teams because participation in 200 Bridges over the years gave them a stronger base of knowledge of who to call for different resources; and they have been able to pass the knowledge along to their peers. The case reviewers from all the partner organizations themselves echoed a parallel sentiment: they themselves now know much more about community resources and best practices in family mobility after sitting at the table problem-solving with many peers from across the community. In other words, the system is that much stronger after 5 years of this work. Over time, DHS has also stood up a larger array of team options to address complex challenges in specific service areas. 

The system is that much stronger after 5 years of this work.

As a result, the Bridges leadership team made the decision to end the pilot in summer 2023. However, we believe it’s important to keep new case workers, especially new nonprofit staff, regularly updated on the resources within the system and who to call for what, as well as familiarizing them with the various tools that came out of the Bridges Out of Poverty initiative, including the Multi-Party Release of Information form and the Social Services Wiki. Going forward, DHS and its partners will host a virtual training twice a year on these tools and contacts within the safety net system for any new case workers and supervisors.

Taking ACF’s economic mobility initiatives forward based on BOP learnings

Soon after the launch of the 200 Bridges pilot in fall 2018, the national Shared Prosperity Partnership called on ACF to convene key local players in the business, government and nonprofit sectors to take bold steps to mitigate the involuntary displacement of our low-income residents. The Shared Prosperity partners — Kresge Foundation, Brookings Metropolitan Policy Program, and Urban Institute– recognized the critical juncture that Arlington is in as it tries to balance inclusivity with tremendous economic growth—and the risk of not doing so.

The journey we took with the 200 Bridges households provides ACF and our partners with ground truth and motivation to do better as a community in sharing our prosperity. We continually take what we have learned to further improve the system. For example, dozens of households in 200 Bridges could not qualify for public housing assistance. We see their crowded living conditions and the basic needs that are unmet. This fueled the urgency for our Shared Prosperity efforts to explore ways to get to housing affordability to a much deeper level than traditionally offered. And, as we saw people foregoing promotions to avoid losing public benefits, we were spurred to action to model the local benefits cliff to shine a light on the broken public benefits system. In 2019, we set a series of bold 5-year Shared Prosperity targets for larger scale solutions around deeply affordable housing, child care and workforce development for Arlington’s lowest income residents. To meet these targets, we continue to partner with State and local government and corporate partners as well as research and philanthropic institutions, including Urban Institute and Kresge Foundation.

This fueled the urgency for our Shared Prosperity efforts to explore ways to get to housing affordability to a much deeper level than traditionally offered.

Even though the last evaluation conducted (2022) shows positive outcomes in housing stability, 200 Bridges participants remain in the “severely rent burdened” range and incomes remain below the federal poverty level! This highlights the tremendous affordability pressures in Arlington as well as systemic failures in wage structures and plausible career pathways at the local, State and Federal levels. These facts are sobering motivators for our Shared Prosperity work in housing, child care and living wage/workforce development policy and as well as our guaranteed income efforts.

Arlington’s Guarantee, launched in 2021 provided $500 per month for 18 months to 200 very low- income Arlington households. We are sharing our results and our voice to advocate for guaranteed income policy at the State and federal levels because we know how transformative the extra bandwidth that monthly cash with no strings attached can be for our low income neighbors.

Our community’s health is tied to theirs. It is the Foundation’s hope that Arlington can be a model for an inclusive economy and community.

For additional information about Arlington Community Foundation’s economic mobility initiatives, contact Anne Vor der Bruegge, Director of Grants and Initiatives.

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