Expanding the conceptual basis of outcomes and their use in the human services

Abstract

Despite the broad-based endorsement of outcomes as appropriate yardsticks by which to measure the merit and worth of human services In a variety of fields of social welfare, the selection, specification, and use of outcomes involve complex sodal and organizational forces. This paper seeks to expand the conceptual basis of outcomes and their use in human services by first considering these forces, and then discussing how outcomes evolve out of the expectations of the powerful, reflect the aspirations of the dispossessed and their advocates, and embody moral perspectives.

THE IDEA THAT HUMAN SERVICE interventions should produce demonstrable change in individuals and their problems has captured the attention of professionals in a variety of social welfare fields. Recent changes to the structure and financing of human services have made outcomes the yardsticks by which to judge these services even more salient and pervasive, as policy makers and funders demand increasingly higher levels of accountability on the part of human service organizations. A diversity of environmental forces are at work legitimizing the use of outcomes in contemporary human service practice, and these forces reflect the considerable change in practice that has occurred over the past 20 years.

This paper places outcomes and their use by human service agencies into a context larger than just a technical one, which is the framework that guides most contemporary discussions of outcomes in the human services. The authors assert that the proper use of outcomes in human service work requires a frame of reference that incorporates cultural and organizational factors. To this end, the authors examine the societal and organizational context of outcomes in human service work and consider how an appreciation of this context can facilitate seeing outcome management as something that entails more than only technical processes of measurement and reporting. This more encompassing perspective on outcomes can help make human service organizations more aware of their organizational cultures and help them become more conscious of how they can use outcomes to advance their practice.

The Call for Outcomes in Human Services

Once, human service professionals could go unchallenged when they invoked values of compassion, justice, equity, and collective welfare to justify their claim on society's resources. It was once enough to act on behalf of people, to offer care, and to engage in service based on deeply held values and commonly shared ethics (Rothstein, 1998). But, with the eclipse of the welfare state and the ascendance of the market as the principal institution of American society, these values increasingly rally less passion. Increasingly, government, corporations, and insurance companies endorse market mechanisms as preferred ways to distribute human services. Outcomes and their use as a management tool is a salient aspect of this form of oversight. Market-like mechanisms and the use of outcomes have emerged in numerous human service fields including child welfare, mental health, physical health, and vocational rehabilitation. But there is a common theme that cuts across these diverse fields. Justifying outcome management is the perspective that human service work must become more rational and more amenable to measurement if it is to be managed properly and effectively.

Today's call for the broad-based use of outcomes in human services comes at a time when the general society is demanding more accountability in a wide range of service sectors. These sectors include income maintenance, health and mental health care, rehabilitation, environmental conservation, primary and secondary education, higher education, and public services. Citizens and their elected officials, for example, are demanding that public school systems demonstrate their merit through annual programs of outcome measurement, which typically involves the quantification of basic education skills and their acquisition and their measurement through student testing. Health care providers operate under increasingly more complex managerial control in which reimbursement is based on an array of outcomes involving patient satisfaction, adherence to standardized protocols or algorithms, and avoidance of negative medical consequences (Tario( & Hales, 2001). Of course, such outcome management and oversight can have perverse consequences like when educators "teach to the test" or health care providers do not treat the patient beyond the standard protocol of care.

The demand for accountability comes at a time of increasing societal wealth. Unfortunately, much of this wealth is concentrated among a narrow range of households and corporations, deepening disparities in affluence between those who occupy the lowest and highest tiers of society. This hyperaffluence at the top of the economic pyramid has been paralleled by a growing conservatism among a broad range of tax-averse citizens. This has led to calls for those organizations that receive public dollars to demonstrate their value to a market-oriented and competitive society that wants its members to achieve autonomy, independence, and self-sufficiency in the least costly manner.

Many citizens-whether individuals or organizations-are suspicious of social welfare and may believe that the management of service by outcomes will make service provision more transparent and rational and, as a result, more businesslike. Managed care, rehabilitation, and mental health programs, for example, are using evaluative tools like report cards as tangible ways to demonstrate their performance, accountability, and ultimately effectiveness. Discrete outcomes can dominate these report cards. They often incorporate measures of performance involving indicants of client satisfaction, client change, and cost benefit. But lay people, recipients, and professionals may have difficulty interpreting these outcomes. This is particularly difficult when comparative data are not standardized or reported consistently and there are no external entities to maintain the data that do not have a stake in the success of service providers.

The call for demonstrable outcomes as a condition for receiving resources reflects a set of values that expects human service work to achieve pragmatic and utilitarian results. From a cultural perspective, human services should make people less dependent on social services and supports, more able to function on their own, and willing to compete in human labor markets. But there is considerable ambiguity in these values. People with serious mental illness who want to work but who obtain jobs in which they find little personal meaning or satisfaction may contribute to a positive agency outcome picture. But, closer scrutiny may reveal that despite high agency placement rates people with disabilities are earning poor wages and receiving inadequate benefits, a problematic situation that fails truly to help people with mental illness to advance the quality of their lives. All outcomes require thresholds of success and often these thresholds are obscured in practice so that service systems, for example, can report their success using outcomes like employment rates and worker productivity without offering a more valid picture of the actual quality of job outcomes from the perspective of their service recipients.

The endorsement of outcomes is not just the domain of conservative groups who call for the achievement of outcomes that are consistent with their ideologies. Liberal and even radical consumer activists in human services also call for outcomes and endorse a results-orientation to the provision of human services (Dykstra, 1995). However, these activists differ from their more conservative counterparts, because they usually advocate the expansion of human services and social supports, calling for a widening of their availability to advance the standard of living and quality of life of people in need. From this more liberal perspective, it is not enough that human service professionals "care about" people, they also need to make substantive changes in the life circumstances and opportunities of the recipients of their services, who are commonly on the margins of society. Indeed, consumer advocates define an important part of their mission as giving voice to demands that professional providers of services produce material or instrumental results in the lives of the people they serve, especially when the social disenfranchisement of service recipients makes it difficult to hear or heed their voices. A good outcome from this perspective is one that raises awareness of the need of service recipients for a higher quality of life, while an even better outcome is actually gaining improvements in their quality of life.

So, while advocates on both the political right and left argue for an outcome-orientation, they are likely to differ substantially in what they see as legitimate outcomes. Conservatives may want people to be more autonomous and less dependent on society, while liberals may call for advancement of the well-being of people on society's margins. Whether or not these value-based positions are seen as "legitimate" is usually determined by the political power of their adherents and their control over resources. This introduces some ambiguity into what is meant by a "good" outcome. Suffice it to say that, while there may be some intrinsically or inherently good outcomes, the ability to legitimize an outcome usually reflects power differentials across groups that strive for the ascension of certain outcomes over others.

Human service organizations operate in dense and turbulent policy and task environments in which a variety of stakeholders frequently exert their influence and assert the primacy of their values. But, maintaining control over the decision about what outcomes they will pursue is also important for human service organizations. And it is important for the people who work in these organizations, especially when they have histories, traditions, and cultures that promote and reinforce certain philosophies and orientations to service. An organization that believes in the inclusion of the people it serves in mainstream community life likely will see the employment of their recipients as an essential outcome of their service process. Rather than placing recipients in low-- paying and marginal jobs, an action that could increase the number of outcomes the agency achieves, and something that its purchasers may prefer, the agency invests its energy in offering vocational and career development to recipients in hope that these services will enable them to secure more permanent and higher paying positions. Nevertheless, the agency may find itself in a quandary with its purchasers because it is seen as failing to get the outcomes these external entities want immediately and at a level of performance they find acceptable.

Whether on the political right or on the left, the emphasis on outcome has legitimized managerial oversight of human service work that basically involves emotional labor and personal commitment. The use of outcomes, which by their nature requires the explication of standards of performance, suggests that, in and of itself, this emotional labor lacks inherent relevance and value, and it requires rationalization within a managerial framework that may serve to prioritize utilitarian results over compassion. This places a burden of proof on human service providers to demonstrate that they produce value for the greater society within a framework of outcomes that is found to be generally consistent with the prevailing culture.

Broadening the Meaning of Outcome in Human Service Work

It is important to note that the call for outcomes in social welfare does not occur in a vacuum. Social forces are at work here that require human service professionals to recognize outcomes as expectations of those who exert power, as aspirations of the dispossessed and those who advocate for them, and as moral challenges. Ultimately, the selection and prioritization of outcomes is a cultural product that reflects what the greater society believes to be the proper work of human services and the results they should produce. But, the mix and interplay of diverse cultural currents and shifting sociopolitical arrangements makes it possible for outcomes to be more that just a reflection of the values of the politically powerful. Sometimes, disenfranchised stakeholder groups have opportunities to define outcomes and shape the focus of human service practice. And, in a society in which ethical and moral traditions run deep, human service practice can strive for more than just helping individuals adapt to mainstream institutions and maintain the status quo.

Outcomes as Fts of the Powerful

Outcomes can reflect the values and complex expectations of funders, regulators, donors, consumers, consumer advocates, and the media, to name just a few. Outcomes-- how they are conceived and measured and how they are used-define expectations and reflect decisions agencies make about how to meet those expectations. The selection of outcomes on which to base the evaluation of human service organizations can substantially alter the cultures of those organizations by introducing new beliefs and assumptions about the nature of organizational work. Most astute administrators understand that their organizations' "outcome set" can be quite complex, creating a challenging context within which to identify and prioritize relevant outcomes. Organizations may need to juggle a broad set of outcomes in different life domains of recipients, particularly if these organizations seek to improve the quality of life of the people they serve. The relative scope of an outcome set, however, may be contingent on an agency's model of service and its philosophical approach. While one organization's outcome set may be quite broad because it seeks to improve quality of life, another organization's set may be quite narrow since it only seeks to create limited and discrete change among its recipients.

So administrators likely make purposeful decisions about their agency's outcome set. They typically seek to address a variety of expectations by giving more or less weight to outcomes, based on the relative influence of those that support them and tempered by the viability and autonomy of their agency. From this perspective, it is likely that those expectations that focus on the "bottom line" of the organization will ascend within the goal set of the agency. Therefore, the outcome package promoted by stakeholders who control or influence funding is likely to receive more attention than outcomes promoted by other stakeholders. A youth service agency that believes it is important to help runaway youth emancipate from their families may find it difficult to pursue this direction in the face of a funding source that wants these children reunited with their families.

Funders, whether governmental bodies, corporations, or private foundations, usually can demand that human service agencies produce the outcomes these stakeholders value, and they usually can require organizations to devote large amounts of resources to their management, and focus their performance on achieving those outcomes. Accreditation, certification, licensing, and regulatory authorities also have a great deal of influence over human service organizations, and an increasing number of them are using outcome-oriented systems for evaluating human service organizations (Meenaghan & Kilty, 1994).

This puts added pressure on human service organizations to engage in outcome-based performance, increases the likelihood that an outcome-orientation will become pervasive among human service organizations, and reduces the likelihood that these organizations will be able to avoid using outcomes as indicators of their effectiveness. What is potentially problematic is that human service professionals may see outcome management merely as a demand for improvements in the technical aspects of program evaluation rather than within a broader matrix of cultural, political, and organizational forces. They can become preoccupied with how to measure factors that account for their performance, instead of gaining insight into the value base of those outcomes that they choose to measure.

The "call for outcomes" can and perhaps should involve social welfare organizations in deep introspection about their purpose, traditions, and core values. Agency leaders who rush to convert societal expectations into agency outcomes may be failing to realize that the uncritical acceptance of some outcomes may be inconsistent with, and may even conflict with the overall direction, traditions, and culture of their agency. Framing outcomes from a purely technical perspective, which merely requires the definition, operationalization, and measurement of outcomes, increases the likelihood that agency leaders will ignore or downplay the fact that some outcomes embody and promote expectations of stakeholders that are not necessarily compatible with the values of the agency. In fact, some agency administrators may find that it is both easier and safer to focus only on the technical aspects of measuring outcomes and ignore the political, social, and moral issues raised by questioning the basis on which they decide which outcomes to measure. This leaves the power differential between those who provide funds and those who need and use those funds as a major determinant of outcomes.

Making outcomes an administrative requirement not only introduces discrete performance expectations; it can also launch a process of organizational coordination and consolidation that can actually alter the structure and form of human service systems. The use of outcomes in the evaluation of organizational performance and the modification of organizational practices requires considerable investment in capacities to capture data about outcomes, transform these data into a useable form, analyze data, and apply the results to altering the performance of the organization.

Building the technical and administrative infrastructure and developing the capacity to conduct such evaluation of outcomes are expensive. These costs are probably difficult for many small- and medium-sized human service agencies to bear. To meet these technical and administrative requirements, human service agencies may need to form federations that join agencies into interorganizational networks that can acquire and share expensive hardware, software, information systems, and evaluation research capabilities. Another strategy is for organizations to consolidate into managed care or service networks. These networks join larger "more fit" organizations with both other large and small organizations. Such consolidation, however, raises the risk of the loss of organizational identity, distinctiveness, and autonomy, a latent intent in a society that seeks to invest less in social welfare and that views organizational consolidation and the reduction of redundancy as ways of controlling the proliferation of human services (Meenaghan & Washington, 1980).

Outcomes as Aspirations of the Dispossessed

Framing outcomes merely as expectations diverts the attention of human service professionals from appreciating the full scope of outcomes as expressions of values. And, framing outcomes exclusively as expectations can short-circuit the achievement of a full appreciation of just how complex outcome management is in today's human service environment.

Viewing outcomes as aspirations focuses attention on how they reflect yearnings, mobilize passions, and represent what people want to achieve for themselves and for others (Markowitz & Rosner, 1996). But many recipients truly are the dispossessed because they may have little say about what happens to them and what amenities and services they seek. Many recipients are marginalized since they may neither have the supports nor the skills to speak on their own behalf. Certainly people with serious disabilities, the homeless, people coping with psychiatric disabilities, and institutionalized persons often are pushed to the margins of society in which resources to support a decent quality of life are limited or nonexistent. Social movements have emerged among human service consumers or among those whose dissent has led to their withdrawal from service systems, and it is the members of these movements who offer alternative, often competing narratives about what people need and how these needs should be met (Moxley & Mowbray, 1997).

In the field of developmental disabilities, advocates have moved beyond normalization to champion the inclusion of recipients in a broad array of community and social roles and in an array of social institutions, most notably in the mainstream of schools, employment, and housing. This contemporary advocacy builds on over 30 years of effort to move people with developmental disabilities from the margins of society, housed largely in congregate care institutions, into neighborhoods. In the 1960s and 1970s, advocates in developmental disabilities articulated aspirations that subsequently were encoded into legal arguments and legal rulings, which have since fortified contemporary advocacy for inclusion and have made person-centered inclusion planning a viable alternative now encoded into many federal and state regulations.

In another example, the aspirations of consumers in the field of serious mental illness legitimized the outcomes of vocational development, employment, supported education, supported community living, and medication-free programs. People struggling with serious mental illness and their advocates also expressed their aspirations through the creation of new service models that demonstrated the strength of self-help and mutual support (Zinman, Harp, & Budd, 1987).

While a number of advances have been made the path to innovation and the expansion of human services has seldom been smooth. For decades before approaches to the community support of people coping with serious mental illness were finally accepted and adopted as important, if not essential, features of progressive mental health systems, mental health professionals ignored many of these practices. And, when professionals in the mental health field finally incorporated these approaches into mental health systems, insurance providers and regulators often held onto old patterns of service delivery. They often required providers of community-based support to comply with standards and reimbursement requirements that were not consistent with the original intent, assumptions, principles, and practices of these consumer-driven services.

But, recipients of service and their advocates have continued to expand the parameters of service, and they have continued to push for the acceptance of new models of how services can be provided. The aspirations of people with physical disabilities have led to the development of independent living centers, which evolved when a movement of people with physical disabilities sought to separate themselves from rehabilitation and medical professionals and from the service delivery systems these professionals controlled. These recipients of service argued simultaneously for control over their own services and inclusion in the greater society (Linton, 1998). The original independent living centers were created to offer community living opportunities based on self-help and mutual support (Charlton, 1998). These original centers also were created to discredit the practices of rehabilitation professionals. Outspoken recipients of service claimed that rehabilitation professionals did not support the outcomes recipients saw as most relevant, particularly those outcomes that focused on the support of every day living and physical mobility (Shapiro, 1993).

The impetus for these innovations came from recipients of human services and their advocates, not necessarily from professionals, who often operated more as adopters than innovators, even though many professionals now claim these practices as their own. Such innovations often reflected the aspirations of marginalized groups. By expressing, promoting, and concretizing aspirations, advocates for these groups, along with some outspoken group members, began the social action needed to mobilize the broader constituencies necessary to obtain the acceptance of outcomes favored by recipients of service. In the case of clubhouses for people coping with mental illness, these outcomes spoke to social support and vocational development. In the case of social clubs for deaf individuals, outcomes spoke to affiliation and social networking (Lane, 1992; Jankowski, 1997). In the case of independent living centers, outcomes focused on enabling people, through self-help and mutual support, to achieve dignified living situations in the community, despite the discrimination and oppression they faced. The acceptance of these outcomes can be traced directly to the social movements that empowered marginalized and disenfranchised recipients of service. These movements reflect "identity politics," in which members of these groups defined their own narratives, and found their own voices in the face of stigma, discrimination, and exclusion (Aronowitz, 1992).

As they sought a voice in determining what services they would receive and what they could achieve for themselves and for members of the groups they represented, marginalized recipients of service began to define new services and new ways services and social support could be provided. Because the outcomes they sought reflected their own aspirations, experiences, and insights into what they needed, the innovations and programs proposed by service recipients focused on practical and direct measures for increasing the benefits those recipients could enjoy in everyday life. Housing, employment, accessible health care, transportation, vocational development, income, friendship, and social support all became important outcomes for recipients, and eventually clinically trained professionals also came to see them as important, especially when these professionals sought to co-opt nascent and emergent consumer movements.

When there is conflict between bureaucratic providers of service and advocates for recipients of services over "what ought to be achieved," organizational expectations and recipient aspirations may collide. This is apparent when advocates and bureaucrats struggle to control the definition of "acceptable" outcomes. For example, a state department of mental retardation, that measures its success through the achievement of outcomes that reflect "minimal but legislatively mandated care," may specify outcomes in narrow ways, confining their measurement to the health or physical status of the individual. Advocates, who have legal responsibility for the protection of individuals with mental retardation under the care of the state government, such as court appointed guardians, or representatives from advocacy and protective service agencies, may demand a broader definition of outcome. They may want service providers to advance the quality of life and life satisfaction of persons suffering from mental retardation; results service providers may see as too abstract, defying measurement, or simply as beyond the scope of their service contracts.

In this situation, advocates may use a variety of collaborative or conflict-oriented tactics to advance the interests of recipients and expand their quality of life. They may demand, push, and cajole providers of care to expend more effort, be more responsive to the individual, and increase the quality of life for recipients of service. Bureaucratic officials, on the other hand, may resist these outcomes, dismissing them as unrealistic. The differences in what stakeholders consider to be legitimate outcomes in this situation are likely to create considerable controversy, foster resentment, flare into open conflict, and even lead to litigation. The collision between advocates and bureaucrats illustrates how outcomes can be contested and thereby create conflict. It also illustrates how changing the substance, direction, and/or magnitude of outcomes can advance the aspirations of a recipient group, even when these exceed the parameters of care that a particular bureaucracy may endorse as the only legitimate and acceptable form of service.

Nevertheless, consensus can emerge between bureaucratic providers and recipients and a common outcome set can evolve. Changing the culture of planning and evaluation activities so that recipients have new roles in articulating outcomes and specifying thresholds of success can enable service systems to build bridges between providers and recipients. Recruiting recipients or their advocates to positions on boards of directors can empower recipients' decision making about the specification, prioritization, and oversight of outcomes (Moxley, 2000). And, developing service roles for recipients can infuse their perspectives and voice into service agencies and enable new outcomes to emerge that may be quite different from those professionals would prescribe (Mowbray & Moxley, 1997).

More radically, recipients could obtain funds or vouchers directly from a governmental authority and have the means to specify their own outcomes and purchase within a market-like forum the services, opportunities, or technologies they see as important to achieve their ends. Service organizations could be circumvented through a variety of strategies in order to empower people in need directly to define and act on their own outcomes. Or, incentives could be offered to service systems to encourage the development of recipient-operated programs, agencies, and even insurance funds that have the power to define and pursue the fulfillment of those outcomes their members or subscribers value.

Aspirations held by service recipients and their advocates are important drivers of innovation in the human services, particularly when professionals are late-stage adopters and not primary innovators of service arrangements. In a number of human service fields, advocates are the ones who identify the outcomes that define the terms of their struggle to motivate human service providers to adopt and normalize new expectations and standards in their work. This struggle is especially meaningful when it melds both means and ends, by linking substantive outcomes to particular strategies and techniques of service provision. In this way, advocates push service providers to achieve the outcomes they believe are important, and to adopt new approaches to service delivery.

There are numerous examples of how recipients and their advocates introduced new outcomes and forms of services to achieve them. In developmental disabilities, the emergence of person centered service provision in the 1990s underscored the necessity for recipients themselves to identify what they valued and what they considered to be important outcomes, without turning to professionals for definitions of what was feasible, possible, or legitimate. Enabling recipients to control the development of their own "person-centered" service plans can be an important outcome since developing such plans provides an opportunity for people who have not previously had a voice in decisions to articulate what they want for themselves and from human service providers.

The outcome of inclusion in developmental disabilities focuses on helping people achieve some semblance of social integration and a sense of community, although funders may feel that such an outcome lies outside their mandate and as such do not willingly underwrite such aspirations. Advocates for older persons, who articulate the outcome of "aging in place," reflect the desire of older people to remain in familiar surroundings. These advocates demand that human service providers extend their vision of service from one that is confined solely to the safety needs of elders to one that encompasses a range of quality-of-life outcomes designed to help older persons maintain themselves in their homes.

Some approaches to service require a much more complex view of outcome than any single agency may have. Wraparound service delivery in child welfare suggests that in order to achieve substantive outcomes that are relevant to a particular child, services must be customized for each child, and service planning and financing must cut across agency boundaries. This is seen as necessary, despite the limits on resources a particular service system may assert or even try to enforce. According to the original wraparound model, outcomes cannot be readily predetermined. They must be formulated through a careful appraisal of each child's situation and an assessment of the community in which the child will live, important considerations for children who are returning to communities from which they have been removed or, in some cases, literally ejected. Here, advocates urge professionals to consider numerous levels of outcome: those that pertain to the child, the child's family, the child's community, and the local human service systems that provide the resources needed to make community living and support possible for a particular child.

An outcome in this situation also may involve attitudinal and behavioral change on the part of human service professionals, who may have to adopt new ways of interacting with a child they once thought unsuitable for inclusion in the everyday life of a community. This suggests that in some situations outcomes are far from discrete, and in fact, they should be seen as multilevel constructs that require the monitoring of change at several different levels and in a number of different systems. Outcomes can even be seen from an ecological perspective that focuses on the integration of different systems to achieve something of value on behalf of a particular recipient.

Outcomes as Moral Perpectives

Although the process of searching for common ground may facilitate the creation of a unified outcome perspective among various stakeholders, establishing such common ground may be frustrated by the moral perspectives that surrounds particular outcomes in some substantive areas of human service. For example, critics of family preservation programs, where the outcome is to keep families of origin intact, may argue that such an outcome could jeopardize children who remain with parents who cannot ensure their safety or adequate development (Gelles, 1996). These critics may call for the placement of children in permanent family situations outside the family of origin, an outcome they say is more appropriate than reunification or family preservation, which they feel can only further jeopardize, if not victimize, children.

In the realm of managed care, providers may limit the scope and content of outcomes through the adoption of "medical necessity" as a criterion guiding service provision, a natural policy product in a society that tends to medicalize human problems (Richardson, 1989). And, they may ration services, so that certain outcomes may be impossible to address. When, for example, a public managed mental health system does not address the employment needs of people coping with serious mental illness, it may fail to provide an important and necessary service, and in so doing, it ignores its moral responsibility to its clients.

Representatives of the mental health system may argue that addressing employment needs falls outside the scope of their mandate and beyond the range of their expertise. But employment outcomes are critical considering the exceedingly high rate of unemployment among recipients of public mental health services; the high value service recipients typically assign to employment, and the importance of these outcomes to the achievement of social integration in American society. Given these reasons, one wonders whether any public mental health system can legitimately ignore the need to help people with mental health problems achieve employment and even prepare for viable careers. Still, some public mental health service providers do not pursue these outcomes, confining their attention only to those outcomes for which they contract, narrowing their visions to the scope and content of the contract, and ignoring other needs they may identify through their day-to-day interactions with the people they serve. For these service providers, if employment is an outcome that lies outside of the scope of their contract, then it is likely that they will not devote any time or resources to achieving it. In fact, the managed care contract and the expectations it incorporates may literally limit the awareness and thinking of service providers, who believe that they are acting properly by delivering only what their reimbursement source is willing to purchase.

The desire of managed care systems to minimize what they provide, to narrow the scope of outcomes they seek and, consequently, to limit the cost and the amount of risk they are willing to embrace, raises serious questions about the propriety, let alone the effectiveness, of such systems of care. In the case of managed mental health care, services may exist only to help people address the most salient and concrete medical features of mental illness, but services designed to help people escape the problematic social status mental illness and its diagnosis creates are likely to be omitted. So, it is not surprising that these systems focus on outcomes that pertain to medical conceptions of mental illness and ignore or disavow responsibility for the negative social consequences the community's response to mental illness can induce. There are alternatives, however. Rather than adopting a criterion of medical necessity as the principal guide to service provision, managed care systems in social and human services can respond to the needs of vulnerable populations by adopting the "necessity to advance quality of life" as an appropriate directive and outcome.

There are some models that introduce transpersonal aims into human services and, as a consequence, they make the appraisal of outcome challenging since the scope of these approaches includes self-expression, selfdevelopment, and spiritual development. For these models, the behavioral specification of outcomes may fail to capture fully the integrity and intent of what they seek to bring about in the lives of people who receive, and provide assistance. Examples of these models include L'Arche, Camphill, and Day House, all of which are grounded in transpersonal values and perspectives that make the provision of human service a moral if not spiritual enterprise. "Outcome" within the context of these moral or spiritual enterprises shifts from a behavioral or materialistic level to a transcendent or transpersonal one.

Conclusion

This paper suggests that outcomes are more than managerial or technical objects but themselves are products of social processes that influence their selection, prioritization, and use within a particular field of human service. But the complexity of outcomes is reflected in the amount of conflict they can engender among groups that have differing if not competing notions of what human services ought to achieve. Within this paper, the authors suggest that outcomes reflect underlying values that certain groups can express as expectations, aspirations, or moral commitments.

"Outcomes as expectations of the powerful" suggest that outcomes actually represent the desired ends of powerful groups who seek to define, explicate, and prioritize their own values and what they believe to be right within a particular field of human services. After these values are concretized into measurement systems, human service professionals and recipients may literally forget whose values these outcomes reflect and how they came to define what is important to achieve or produce in a particular field. "Outcomes as aspirations of the dispossessed" suggest that those groups without formal power will seek to add their values to the mix of legitimate outcomes. Like powerful and dominant groups, these groups possess their own values that they can articulate as the basis of the outcomes of service and policy systems on which they may be very dependent for important services, supports, and opportunities. These two sources of outcome suggest that contemporary systems of evaluation and accountability will reflect a mix of values and outcomes reflecting what funders and regulators of human services deem as important and what consumers and their advocates see as important.

Whether outcomes come from the powerful or dispossessed there is the likelihood that they reflect moral commitments on part of the people who endorse them or who take exception with them. Most human services reflect deep commitments on the part of people, and models emerge within various fields that can create great debate about what is good and what is not good. Some of these models seek to transcend materialistic values and to define new relationships between the members of marginalized groups and their society, or between people and a transcendent world. It is these models that can raise basic questions about what constitutes relevant outcomes and how to measure outcomes in ways that are consistent with the integrity of particular models of service.

Ultimately, however, the specification, measurement, and use of outcomes in the human services increasingly finds legitimacy and likely will continue to be an important priority of contemporary human service delivery. Although it is easy to focus only on the technical aspects of outcomes, it is equally important to question why particular outcomes are even important enough to measure, whose values they reflect, and why certain outcomes are considered more legitimate than others. It is these considerations that make outcomes in human services potentially controversial and perhaps even divisive.

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David P Moxley, is professor, and Roger W Manila is adjunct professor, School of Social Work Wayne State University, 314 Thompson Home, Detroit, MI, 48202. David Moxley's e-mail address is david.moxley@wayne.edu.

Manuscript received: September 18, 2000

Revised: September 25, 2001

Accepted: September 27, 2001

Copyright Families in Society Nov/Dec 2001
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