Southeastern Connecticut Council of Governments – Gap Analysis

Prepared for the Southeastern Connecticut Council of Governments by Interim Executive Solutions, Inc.

Executive Summary

This gap analysis brings together two “big data” sources— Connecticut Economic Resource Center (CERC) town profiles and United Way’s 211CT data—alongside interviews with municipal officials and nonprofits to identify gaps in service delivery in southeastern Connecticut. We use demographic and financial data by municipality and region to offer a socio-economic backdrop to the regional human services ecosystem. We then explore unmet human services needs by municipality and the region overall. Finally, we offer perspectives on patterns of unmet need, assessments of the information available, and recommendations to address the institutional misalignments that contribute to regional service gaps. This report is complementary to the SCCOG Human Services Providers Shared Services Study produced during the same time period.

Based on a thorough analysis of data from CERC town profiles and 211CT, the highest areas of unmet service needs included housing and shelter, mental health and addictions, health care, and employment and income. However, when overlaid with providers delivering each of these services in the region, there appears to be a proportionate number of service providers offering coverage for these areas of need. Apart from employment and income services, the top human service needs in the region are also the top services provided.

Presented with this enigma of high levels of unmet needs in areas of high service provision, Interim Executive Solutions (IES) needed to look beyond the numbers to identify service gaps. We determined that the region’s service gaps are related to coordination versus provision. This prompted our team to develop a new paradigm for viewing human services coordination in the region, metaphorically much like the health care system. Municipalities delivering human services are skilled at providing general services and short-term emergency services. Given these strengths, they are much like a family doctor or general practitioner. They can identify residents needing services, facilitate local policies to help address patterns of human service needs, and arrange eligibility for and referrals to more specialized human services providers. Nonprofits usually provide specialized human services. Most, though not all, have built up their expertise and internal business models to provide services to a specific client group or around a particular area of need.

Recognizing the more general role fulfilled by municipalities to maintain wellness, conduct screenings, identify problems, and make appropriate referrals as well as the nonprofit specialist role with the specific knowledge, training, and treatment expertise to be able to address more narrowly defined clientele, IES finds two key gaps. First, there is a gap in funding for human services providers and the infrastructure required to connect individuals needing services with service nodes—specialist hubs in the region’s cities. IES highlights transportation as the principle funding gap inhibiting a smooth connection between needy citizens and the services they require. Second, coordination and communication between municipalities and nonprofits is not always fluid nor uniformly structured across the region. IES focuses in on the inadequacy of the current 211CT database to demonstrate this disconnect.

IES makes four key recommendations in light of these findings.

  • More state funding is needed for human services and fundamental infrastructure in the region. IES suggests that the region approach this task through a “Pay for Success” model.
  • For residents of southeastern Connecticut, 211CT should be further developed as a mobile application that allows users to set a location radius and key word search for services within that radius. For policy-makers, 211CT should make its service categories collapsible so that the data is easier to manage and analyze. For all stakeholders, a concentrated effort should be made to increase provider participation rates.
  • Additional communication paths and systems that are “risk free” or incentivized are needed.
  • Service providers should also look to build upon service coordination best practices in the region. Municipalities without a human service capacity should consider right-sizing their service models to align with their community’s level of need. Nonprofits should leverage their specialist skill-set and resources to provide high-quality, targeted interventions to the populations they serve.


IES acknowledges the participating twenty-eight nonprofit organizations, eight municipal governments, and one Tribal Nation for their engagement with our consultant team and forthcoming provision of service provision and gaps data used to prepare the analysis outlined in this report. We appreciate especially the time and dedication of senior leaders that engaged in our interviews and responded to our surveys as co-creators of knowledge and influence in the human services sector in southeastern Connecticut.


 The Southeastern Connecticut Council of Governments is one of nine Councils of Governments (COGs) in the state. Collectively the COGs provide a geographic framework within which municipalities can jointly address common interests and coordinate those interests with state planning processes. The municipalities within each region have voluntarily created a Regional Council of Governments (RCOG) through local ordinance to carry out a variety of regional planning and other activities on their behalf. SCCOG is comprised of twenty-two towns, cities and boroughs, and is governed by the chief elected officials of member municipalities. SCCOG’s member municipalities are Bozrah, Colchester, East Lyme, Franklin, Griswold, Groton (City), Groton (Town), Jewett City (Borough), Lebanon, Ledyard, Lisbon, Montville, New London, North Stonington, Norwich, Preston, Salem, Sprague, Stonington, Stonington (Borough), Waterford and Windham. The region spans 616 square miles and is home to approximately 286,000 residents.

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 About IES

IES focuses on providing interim executives and leadership coaching for nonprofit organizations and their boards. We bring together a pool of highly experienced senior nonprofit executives who provide transitional leadership or specialized consulting for nonprofits undergoing periods of leadership, strategic change, and capacity building. Clients can engage with our senior level professionals on an individual basis or benefit from a team of complementary experts working in collaboration to resolve interconnected issues.

IES consultant team:

Project Manager:  N. Paul TonThat

Group Leader, Nonprofits:  Dr. Byron T. Alex

Group Leader, Nonprofits:  Thomas Colligan

Group Leader, Nonprofits:  Gloria Franqui

Group Leader, Municipalities & Gap Analysis:  Barbara Thornton

Data, Analysis, Writing:  Dr. Marcia Mundt


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Index of Acronyms and Abbreviations


CERC – Connecticut Economic Resource Center

C&FS – Children & Family Services

COGs – Councils of Governments

COMO – Stonington Community Center

CT – Connecticut

GP – General Practitioner

IES – Interim Executive Solutions

LLHD – Ledge Light Health District

RCOG – Regional Council of Governments

SCCOG – Southeastern Connecticut Council of Governments

TVCCA – Thames Valley Council for Community Action

UCFS – United Community & Family Services

WAIM – Windham Area Interfaith Ministry


Table of Contents


Executive Summary 2

About SCCOG_ 4

About IES_ 4

Index of Acronyms and Abbreviations 6

Overview_ 8

Purpose 8

Data Sources 8

Human Service Needs and Unmet Needs 10

Needs and Unmet Needs According to CERC Data 10

Needs and Unmet Needs According to 211CT Data 12

Needs and Unmet Needs According to Municipal Officials 17

Output Gaps in Human Services Provision_ 19

Human Services Provision and Coordination_ 20

Input Gaps in Human Services Provision_ 23

Health Care as a Metaphor for the Human Services Network_ 24

Identified Gaps in Human Service Provision in the Region_ 33

Lack of Adequate Funding for Key Services Provided by the State 34

Inadequate Lines of Communication and Cooperation_ 37

Challenges and Limitations of the Gap Analysis 40

Recommendations 42

Appendices 47





This report is intended to support and provide additional context for the final report of the SCCOG Human Services Providers Shared Services Study, also prepared by IES. While the final report relies primarily on interviews, surveys, and administrative records from organizations participating in the study to provide findings and recommendations, this gap analysis relies up on big data from sources like United Way’s 211CT, the Connecticut Economic Resource Center town profiles, geographic information systems mapping, and 990 tax records to identify areas of greatest need both geographically and by service type in the region. Based on IES findings regarding unmet needs and provision coordination gaps, this analysis concludes with a set of recommendations for how to close these gaps in service in the future.


Data Sources


We begin with a short overview of the two primary big data sources used to generate this gap analysis as well as a brief discussion of the municipal and nonprofit human service provider interviews used to identify the nuances and key characteristics of need and human services provision in the region.


The Connecticut Economic Resource Center compiles various socio-economic indicators into town profiles, showing the key characteristics and differences between municipalities in Connecticut. This data we used to explore how demographic differences between municipalities in southeastern Connecticut contribute to the demand for services. Although CERC data can be stratified at a regional level, profiles are not provided by COG region, thus IES has identified municipalities of greatest human services need based on comparison of each municipality to state and New London County averages. New London County is the closest proxy territory for the SCCOG region, as it includes all SCCOG municipalities except for Windham. High-level indicators included in this dataset and analyzed by IES are population, square mileage, population density, poverty level, education level, and household income.


United Way’s 211CT database tracks 2-1-1 service request callers and organizations that have registered to receive referrals via this system by service type. Using this data, our team identified three major trends that characterize human services needs in southeastern Connecticut outlined in the relevant section below. It divides human services into 15 core categories including: housing, income, mental health, substance abuse, older adults, re-entry, health care, utility assistance, food, legal assistance, transportation, children and families, crisis, volunteer, and youth. These categories closely parallel the service categories used by SCCOG in its 2016 directory. Organizations listed in the 211CT database include nonprofits, municipal human services departments, for-profits, as well as state and federal agencies.


A final data source used in the production of this gap analysis is a series of nonprofit and municipal interviews conducted by IES consultants. These interviews serve to tease out the nuances of trends identified in the analysis of the two “big data” sources discussed previously. Of the 19 municipalities in the region, SCCOG had previously identified eight municipal governments and one Tribal Nation with dedicated human services capacity as well as over 20 human services nonprofits. IES interviews with each of these agencies were semi-structured and conducted from March to August of 2018, often in multiple rounds. The first interview with an official of each municipal human services agency was conducted in person, follow-up questions were answered via phone or email. Nonprofit interviews were typically conducted via phone, and follow-up questions were facilitated via email.



Regional Human Service Needs and Unmet Needs


Needs and Unmet Needs According to CERC Data


CERC municipal socio-economic profiles for southeastern Connecticut show a wide range of diversity in terms of human service needs. The primary pattern of service need in the region is that larger, urban municipalities with a higher population density tend to have greater service needs than smaller, less densely populated municipalities. The paragraphs to follow indicate how the IES analysis of CERC data proceeded and highlight those municipalities that likely require a greater human services support network given their reported socio-demographic characteristics.


Table 1 below shows key CERC data points for each municipality in the SCCOG region and compares municipal data to New London County and state level data. New London County and state data are listed at the top of the table, highlighted in grey. Municipal data is then listed in alphabetical order below. In general, New London County underperforms the state on all indicators of socio-economic status IES reviewed including poverty level, educational attainment, and median household income. Municipalities reporting a socio-demographic statistic worse than the state average are highlighted in lighter red, and municipalities reporting a socio-demographic statistic worse than the New London County average are highlighted in darker red.


Analyzing the data by indicator, we find that three municipalities have poverty levels more than five percentage points above the regional average. Child poverty for those under the age of 18 is a graver issue for the region than total poverty as 37% of municipalities in the region report poverty levels above the state average for this demographic group. Five municipalities have lower high school graduation rates than the state average, whereas all but six municipalities report a lower percentage of the population having completed a four-year bachelor’s degree. Eight of the municipalities have a median annual household income below the median for the region.


Looking across the key socio-economic indicators by municipality, six municipalities present the greatest level of need for human services given that poverty levels are higher, educational attainment is lower, and median household income is lower than the state and/or regional average. These municipalities include, in alphabetical order: Griswold, Groton, New London, Norwich, Sprague, and Windham. Three of the six are larger, urban cities. These three municipalities—New London, Norwich, and Groton—are the only cities in the region. Thus, 100% of cities in southeastern Connecticut report disadvantaged socio-economic characteristics across all indicator areas as opposed to only 19% of smaller, primarily rural towns. New London, with a relatively high population density, and Windham, with a relatively low population density, are the municipalities with the largest negative discrepancies from the state average or median across socio-economic indicators.


Table 1: CERC Socio-Economic Indicators by Municipality


Needs and Unmet Needs According to 211CT Data


Given this demographic backdrop, we turn now to 211CT data to discuss the major trends in human services requests and response by municipality and service type. Three key trends emerge from this discussion as detailed below.

The first major trend identified by 211CT data is that major metropolitan areas in the region experience a far higher per capita number of calls than other municipalities in the region. Figure 1 below shows the requests for services per 1,000 residents made through 211CT for the SCCOG region as a whole, for the “local average” municipality, and for each of the SCCOG member municipalities listed in alphabetical order.


Figure 1: 211CT Requests by Municipality (per 1,000 residents) from March 2017 to March 2018


Source: United Way of Connecticut. (2018). 211CT. Retrieved from


As is clearly demonstrated by Figure 1, New London, Norwich, and Windham have significantly higher rates of 211CT request calls than the rest of the municipalities at 280, 139, and 140 calls per 1,000 residents respectively. Griswold & Lisbon, Sprague, and Groton average around 50 to 75 calls per 1,000 residents. The per capita request rate, in descending order by municipality is: New London, Windham, Norwich, Griswold & Lisbon, Sprague, Groton, Preston, Bozrah, Colchester, Montville, Salem, Waterford, Ledyard, East Lyme, Lebanon, Stonington, Franklin, North Stonington.


A second trend emerging from the 211CT caller data is that housing & shelter are the most common requests in the region. Requests for mental health and addiction, though also high, come in at a distant second. Several services are not regularly requested at all through 211CT including crisis, older adult support, re-entry, substance abuse, volunteer, and youth services. Table 2 below shows the percentage and number of 211CT request calls by service type in descending order over a one-year sample of callers from March 2017 to March 2018.


Table 2: 211CT Calls by Service Type in Southeastern Connecticut from March 2017 to March 2018


Again, calls for these two most common types of requests are focused in New London, Norwich, and Windham. However, requests for mental health and addiction services are also high in Griswold & Lisbon. Digging into the data bit more deeply, we find that most requests for housing & shelter are for shelter directly as opposed to other services grouped in this category such as rent assistance, home repair, or landlord-tenant dispute resolution. Figure 2 shows the shelter-related requests for each of the SCCOG municipalities.


Figure 2: 211CT Requests for Shelter by Municipality (per 1,000 residents) from March 2017 to March 2018

Source: United Way of Connecticut. (2018). 211CT. Retrieved from


In the area of mental health & addictions, mental health services are most frequently requested, but crisis intervention & suicide is also requested at a high rate. Figure 3 shows the mental health services-related requests per 1,000 residents over the period from March 2017 to March 2018, and Figure 4 shows the crisis intervention and suicide-related requests per 1,000 residents over the same period.


Figure 3: 211CT Requests for Mental Health Services by Municipality (per 1,000 residents) from March 2017 to March 2018

Source: United Way of Connecticut. (2018). 211CT. Retrieved from


Figure 4: 211CT Requests for Crisis Intervention and Suicide Services by Municipality (per 1,000 residents) from March 2017 to March 2018


Even though 211CT received the reported number of callers by category as listed here, not all calls received can be resolved or directed. The 211CT database tracks these unresolved cases, illuminating unmet needs in the region. Delving into this data by service sub-category reveals the below enumerated top ten areas of unmet need in the region.


Top 10 Unmet Needs in the Region




Table 3: 211CT Unmet Needs by Municipality in Southeastern Connecticut

Housing & Shelter  Food  Health Care Utility Assistance Mental Health & Addictions  Employment & Income  Clothing & Household  Child Care & Parenting  Government & Legal  Transportation Assistance  Education  Disaster  Other  Total Unmet Needs
All Region 1357 117 77 182 179 608 57 5 82 38 7 58 135 2902
New London 423 38 24 40 52 201 14 2 28 14 2 21 38 897
Norwich 432 28 16 67 22 201 20 3 13 5 2 6 26 840
Windham 156 13 6 2 9 56 1 0 5 6 2 8 9 272
Groton 111 12 14 10 16 54 5 0 9 5 0 4 14 254
Griswold/Lisbon 56 3 3 13 18 27 2 0 5 3 1 2 9 142
Montville 37 5 1 7 6 11 2 0 2 3 0 4 0 78
Colchester 26 2 2 8 8 13 0 0 3 0 0 2 6 70
Stonington 16 2 2 5 17 3 8 0 1 0 0 3 12 69
Waterford 17 4 4 7 8 20 2 0 0 0 0 2 2 67
Ledyard 32 1 1 2 4 6 0 0 1 0 0 2 3 52
East Lyme 24 5 0 6 4 6 0 0 2 0 0 0 4 51
Sprague 15 0 0 6 1 3 2 0 0 0 0 1 0 28
Preston 6 1 0 6 6 3 0 0 0 0 0 0 2 24
Bozrah 6 0 0 1 4 4 0 0 0 0 0 1 0 16
Lebanon 0 0 0 1 2 1 0 0 3 0 0 2 0 9
North Stonington 2 2 0 0 0 0 0 0 1 0 0 0 0 5
Salem 2 0 0 0 0 1 0 0 0 0 0 0 1 4
Franklin 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Source: United Way of Connecticut. (2018). 211CT. Retrieved from


This data suggests that there are indeed gaps in the human services system in the region. By far the highest unmet needs are housing & shelter, employment & income, utilities, and mental health & addictions. Furthermore, geographically these gaps align with the anticipated municipalities of greatest human services need based on the socio-economic indicators in the CERC town profiles analyzed previously.


However, there are two caveats to the way the 211CT database has been created that should be considered before concluding that reported unmet needs translate to true gaps in service in the region.


First, not all service providers in the region are included in 211CT database. For example, the database has two or fewer service providers associated with three of the top five service categories: employment & income, utilities, and mental health & addictions. Thus, 211CT callers may not be referred to a provider in these categories not because the service does not exist, but because the service provider is unregistered with United Way’s 211CT system. This caveat to relying upon 211CT data to draw conclusions is further emphasized once we compare agencies participating in the SCCOG Human Services Providers Shared Services Study, which a former SCCOG study cited as “those generally acknowledged to be working in the human services field or the ‘backbone’ of local human services,” with the 211CT list. This exercise shows that only 17 out of the 37 participating agencies, 46%, are not even listed in the 211CT system.


Second, there are a variety of reasons that a request for service may have been classified as an “unmet need.” It could be that callers are not referred due to the distance between the listed service provider and the individual’s home town or simply due to failed referral communication. This makes it impossible to say with any certainty whether these service requests called in to 211CT are really “unmet.”


In summary, while this data source can be considered reliable in revealing areas of service need, it does not offer definitive evidence of unmet need.


Needs and Unmet Needs According to Municipal Officials


While “big data” can be a powerful tool for analysis of service gaps in southeastern Connecticut, it does not necessarily tell the entire story. Triangulating data sources and types is a typical strategy for overcoming possible knowledge gaps in “big data” analyses and teasing out important nuances. Thus, in addition to the CERC and 211CT data sources, IES interviewed a sub-set of municipalities and nonprofit agencies in the region to gain additional insights on service needs and gaps in the region. Table 4 below shows the perceived gaps in service as reported by municipal human services agency staff in this sub-set of municipalities.


Table 4: Perceived Gaps in Service by Municipality

Service Categories Groton Ledyard Montville New London Norwich Stonington Waterford Windham Total Gaps in Service
Children & Families 0
Crisis X 1
Food 0
Health Care X X 2
Housing X X X X 4
Employment & Income X X 2
Government & Legal X 1
Mental Health & Addictions X 1
Older Adults 0
Re-Entry X X X X 4
Substance Abuse X 1
Transportation X X X 3
Utility Assistance X 1
Volunteering X 1
Youth 0
Clothing & Household 0
Education 0
Disaster 0
Total 0 1 5 7 0 1 7 0

Source: IES municipal human service agency interviews.


Table 4 shows that the key finding from CERC data, reflecting a high level of service need in cities, is not necessarily supported by municipal interview data. Only New London reports unmet needs whereas Norwich and Groton assert that there are no unmet needs. Table 4 also indicates that municipalities largely corroborate the trend identified by the 211CT data with regards to housing & shelter as an unmet need in the region. However, municipalities highlight two other areas of need that the 211CT data does not: re-entry assistance for those coming out of a period of incarceration and transportation.

Output Gaps in Human Services Provision


Triangulating the findings from CERC town profiles, 211CT data, and the subjective perceptions of municipal human services providers suggests the following service gap trends in the region:


  1. Cities tend to have the highest level of need and report the most unmet needs.
  2. Housing & shelter is the greatest human services need requested and reported as unmet in the region according to multiple sources.


However, these various data sources provide an incomplete picture of service provision in the region. The data described thus far only hints at possible gaps by showing service network outputs based on data sources that each do not provide a complete or conclusive picture of need or gaps in the region. The data analyzed thus far does not describe the inputs of the human services providers or how service provision is coordinated in the region, to which we turn in the subsequent section.


Human Services Provision and Coordination


In order to explore whether the needs for human services provision displayed by CERC town profiles, 211CT caller data, and municipal reported perceptions are indeed being addressed by the human services provider network in the region, IES compiled an inventory of service providers in southeastern Connecticut. Appendix #2 includes the full inventory compiled from organizations registered with 211CT and participating human services agencies in the SCCOG Human Services Providers Shared Services Study. Service providers include a wide range of entities including nonprofits, for-profits, municipal governments, as well as state and federal agencies. For each record, we have noted location, organization type, services provided, and the source which we used to identify the agency.


In the paragraphs to follow, we pull from our own inventory of service providers in southeastern Connecticut to determine if there is a mismatch between service requests and provision in terms of geography and service type. Although not all the agencies in our inventory were included in the 211CT data, IES has used the 211CT service categories to classify all human services agencies on our list for consistency and comparability with the prior section. In each of the tables below, we provide descriptive statistics about human services agencies in the region overall and the sub-set that participated in the SCCOG Human Services Providers Shared Services Study. With this data, it is possible to directly compare services offered in the region with the unmet needs identified by 211CT data.


With regards to the location of service provision in the region, human services agencies are indeed concentrated in the highest areas of need both in terms of socio-economic profile and service needs. Table 5 below offers a count of human services providers in southeastern Connecticut by municipality, listed in order of number of providers located within the municipality, as outlined in our inventory. All three cities, which reported disadvantaged socio-economic profiles per CERC data, are at the top of the provider list. Cities and towns with the highest number of 211CT requests per 1,000 residents, as noted in the section above, were New London, Norwich, Griswold, Sprague, and Groton. As shown in Table 5 below, four of the municipalities reporting the highest number of 211CT requests are reflected in the top five municipalities with the highest number of human service providers. Indeed, only Sprague, the third smallest municipality in the region in terms of population, appears to have a disproportionate ratio of need to service providers.


Table 5: Number of Service Providers in Southeastern Connecticut by Municipality

Municipality Number of

Providers in Inventory Offering Service

Number of

Study Participants Offering Service

Norwich 36 11
New London 33 9
Groton 12 3
Windham 7 4
Griswold 6 1
Waterford 6 1
Ledyard 4 1
Montville 3 1
Stonington 2 1
Preston 2 0
Lebanon 2 1
Colchester 1 0
Sprague 1 0
Bozrah 1 0
Franklin 1 0
East Lyme 0 0
North Stonington 0 0
Salem 0 0
Lisbon 0 0
Outside Region 7 4

Source: IES inventory of human service providers (see Appendix).


Thus, based on geography alone, it appears that there is not really a gap between areas of need and location of service provision except for Sprague as an outlier. However, when looking to 211CT data on unmet needs, versus socio-economic data or service requests, the findings do not add up. Ironically, even though most human services providers are located in Norwich and New London, these two cities report the highest numbers of unmet needs.


Turning now to the services offered, human services agencies again appear to be focusing their efforts on the most pressing areas of needs in the region. Table 6 below offers a count of human services providers in southeastern Connecticut by service category, listed in order of number of providers per category, as outlined in our inventory. The data shows that housing & shelter, health care, food, children & families, and mental health & addictions are the most common services provided in the region. 211CT data cited earlier showed that the highest number of service requests were related to housing & shelter, mental health & additions, health care, employment & income, and utility assistance, in that order. Three of these top five requested services are among the top five most commonly provided services in the region. Employment & income as well as utility assistance appear to be underserved in the region.


Table 6: Number of Service Providers in Southeastern Connecticut by Service Type

Service Category Number of

Providers in Inventory Offering Service

Number of

Study Participants

Offering Service

Housing & Shelter 50 16
Health Care & Disabled Services 37 13
Food 32 13
Mental Health & Addictions 24 18
Children & Families 22 16
Youth 16 11
Older Adults 15 11
Substance Abuse 14 13
Employment & Income 14 11
Utility Assistance 11 9
Crisis 11 9
Education 9 9
Volunteering 8 8
Clothing & Household 8 8
Transportation 6 5
Re-Entry 5 5
Government & Legal Assistance 5 4
Other 5 4
Disaster 3 3

Source: IES inventory of human service providers (see Appendix).


While unmet needs in the areas of employment & income and utility assistance appear to align with weaknesses in service provision in the region, the remaining data on service type is incongruent with 211CT reported unmet needs. The top five unmet needs identified in the prior section included housing & shelter, employment & income, utility assistance, mental health & addictions, and food. Again, this finding does not add up with this provider data. It suggests, for example, that even though nearly 40% of the human services providers in the region provide housing & shelter services, 211CT is unable to resolve a high number of these caller requests.


Input Gaps in Human Services Provision


At this stage, the comparison of data on both outputs (unmet needs) and inputs (service provision) of the human services provider network indicates that there is not really a significant gap in service provision by geography or service type. The outlier case in terms of geography is the municipality of Sprague, which does appear to lack human services providers given its socio-demographic profile. However, it would not necessarily make sense to suggest that more nonprofits move into the one of the smallest municipalities in the region. The outlier cases in terms of service type are employment & income as well as utility assistance, of which there are fewer providers in the region than may be needed to address this need. The data does not delve into the capacity level of human services provider in those agencies that address these areas of need, however; so, it may be that the number of providers is sufficient if service is scaled appropriately. Thus, beyond these outlier cases, it appears that the majority of service provider energy is indeed being directed to the right services in the right places. Yet, there continues to be a phenomenon of unmet needs, even in areas where service providers are concentrating their efforts.


This finding indicates the need to go beyond seeking linear gaps between service requests and service provision; it is necessary, in this case, to seek clarity on points of failure within the human services ecosystem itself.


To accomplish this task, we turn to the data collected in production of the SCCOG Human Services Providers Shared Services Study. As part of this study, IES conducted interviews with twenty-eight nonprofits, eight municipal human services agencies, and one tribal nation to better understand the human services network in the region. In the tables above, we provided the distribution of the agencies participating in our study in terms of geography and service categories. We do this to demonstrate that, generally, participating agencies are distributed similarly to the overall inventory of service providers in the region. The only notable case of oversampling is in the categories of mental health & addictions and substance abuse. Indeed, nearly all the service providers offering substance abuse are on the participating agency list. This indicates that this set of participating agencies should not be considered a statistically representative sample. We cannot therefore directly generalize the perspectives they share to the service network overall; however, their experiences and perspectives can still speak to service provision nuances in the region.


As the purpose of this study was to identify gaps in service provision with an emphasis on municipalities and nonprofits as principle service providers in the region, we will now focus in on the role of each within the broader human services network in southeastern Connecticut.


Health Care as a Metaphor for the Human Services Network


Based on our interviews with participating agencies, IES offers a new story, or paradigm, for understanding the regional human services ecosystem, including its network of stakeholders and providers. The metaphor we offer to describe the human services network is that of the health care system. Within the health care system, those in both good and poor health are considered patients.  The General Practitioner (GP) doctor works with all patients to maintain the health of individuals and families. Yet, when a more serious illness presents, the GP assesses the situation and refers the individual to the appropriate specialist.


The health care system recognizes that there is a need for an easily accessible, first line of defense GP to maintain wellness, conduct screenings, identify problems, and make appropriate referrals. The system also recognizes that the GP cannot do it all. And therefore, it has encouraged the development of specialists with the specific knowledge, training, and treatment expertise to be able to treat ailments that present specialty characteristics.


This metaphor translates well to the paradigm IES has observed in action across southeastern Connecticut. Municipalities play a key role in providing human services to all residents, effectively serving as the “GP” for maintaining wellness and for providing information, referral, and even enrollment with “specialist” nonprofit organizations, which are each uniquely tooled to respond to a specific, and often narrowly defined, service area.


Municipalities as Service Providers: General Practitioners


The function of municipal human services officials and departments within the human services ecosystem is important because they are associated with a well-known entity amongst residents—the City or Town. Municipal human services staff are on the front line, working as the primary “touch point” for citizens in need who do not know how to access or manage the broader, complex, and hard to maneuver, human services system. Citizens who need help, but are not sure where to go, are likely to turn to a local source of information such as neighborhood libraries or the City or Town Hall. At this point, the citizen is using the municipality as a GP for their human services need.


Table 7 shows the services either offered directly or facilitated through each municipality’s human services department according to municipal officials. Note that housing is often coordinated through housing authorities, and education via schools; thus, these services are generally not even perceived as “human services” because they are so highly integrated into the municipal anatomy.


Table 7: Services Provided by Municipality

Service Categories Groton Ledyard Montville New London Norwich Stonington Waterford Windham Number of Municipalities Offering Service
Children & Families X X X X X X 6
Crisis X X X X X X 6
Food X X X X X X 6
Health Care X X X 3
Housing X X X 3
Employment & Income X X X X 4
Government & Legal X X X 3
Mental Health & Addictions X X X X X 5
Older Adults X X X X X X X X 7
Re-Entry X X 2
Substance Abuse X X X X 4
Transportation X X X 3
Utility Assistance X X X X X X 6
Volunteering X X X X X X 6
Youth X X X X X X X X 8
Clothing & Household X X X X X 5
Education X X X X X 5
Disaster X X X X X X X 7

Source: IES municipal human service agency interviews.

Municipalities have evolved their own “best practices” for accepting these human services related questions and forwarding them to the most relevant municipal department or outside specialist agency. In our investigations, the department usually responsible for this task falls under the banner of Human (Social) Services, Youth Services, or the Senior Center. Many municipalities routinely raise human services issues at general staff meetings. In these cases, a family is might be getting evicted and Inspectional Services requests help or the police may have apprehended some youths who need juvenile assistance. Other municipalities have a standing committee composed of selected municipal staff and outside experts like representatives from local nonprofits. Some municipalities, like those with dedicated human services offices participating in this study, create special departments for coordinating human service needs. They generally find that this set-up makes the delivery of municipal services across all departments more efficient and more effective for their citizenry. The SPOTLIGHT: Norwich as a General Practitioner highlights how one participating municipal human services provider coordinates a wide variety of services for residents in the City of Norwich.

IES has created a set of models to describe the way municipalities in the region approach the task of GP. Every municipality has a building staffed with publicly-paid officials who can, and often do, take questions from the public—including questions about human services. Citizens, depending on their situation, may first encounter a school administrator or a reference librarian to attempt to meet their service needs. The range of municipal officials who might be approached for information about human services frequently includes staff in the following departments: 1) Fire, 2) Housing Authority, 3) Inspectional Services, 4) Library, 5) Human (Social) Services, 6) Parks & Recreation, 7) Police, 8) School, 9) Senior Center, 10) Youth Services, 11) Veteran’s Affairs, 12) Public Officials such as the Mayor or Selectman.


Over the course of this investigation, IES has identified five different models of municipal human services in existence in the SCCOG region. Our eight participating municipalities can be classified into the first three models; we indicate where they fall in parentheses after each model is described below.


  1. Human Services Department. Municipalities that have established a department dedicated to human services will often appoint a director, hire on a full staff, and oversee an allocated services budget. They develop human services programs, deliver services directly, and coordinate community resources on behalf of citizens. (For example: Groton, Montville, Norwich, Stonington, Waterford, Windham)


  1. Human Services Policy Director. Municipalities with a policy director have an individual assigned to advocate for human services within the municipality. This person works through policies, programs, municipal departments, other agencies, and private organizations serving the community to align resources effectively. They take responsibility for the general wellbeing of the citizenry via recreation, youth activities, and senior services, as well as providing referrals and case management for citizens. (For example: New London)


  1. Human Services-Related Agency. Municipalities with a human services-related agency tend to have a director who develops procedures to coordinate services among all departments, leads case management on specific citizen needs, and sometimes develops services in response to the community’s long-term needs. (For example: Ledyard)


  1. Human Services Officer. Municipalities will sometimes appoint a municipal staff person who is tasked with working on behalf of a specific population group like youth, veterans, or the elderly. This individual is also expected to be the point-person for answering human services-related questions that may come to the Town or City through other departments.


  1. Human Services Generic Function. Every municipality provides some human services functions and/or encounters and attempts to resolve human services-type issues. If no human services capacity is specifically designated within the municipality, directing human services requests falls to a variety of different municipal departments. The departments most commonly stepping into this role can vary from one municipality to the next depending on organizational culture and citizen needs.


Nonprofits as Service Providers: Specialists


Most nonprofits are mission directed, focused on a specific population group or service category. Nonprofit human services agencies tend to focus on areas requiring deep knowledge and expertise, perhaps even certification. Services that fall into the categories of mental health & addictions, substance abuse, health care, and children & families, for example, often require a special license or even a specialized degree in order to deliver the service.  Building and running housing programs, managing governmental eligibility requirements for health care, including third-party payments, and providing expert clinical or psychological services are examples of the top categories of services provided by nonprofit “specialists” in the region. SPOTLIGHT: Specialist Care for Homeless Families with Children at Always Home shows the vital role that specialist organizations play for populations with high-risk, niche needs.


Table 8 shows the service categories that each municipal human services provider refers out to nonprofits according to municipal officials. While referrals to nonprofits are made in nearly all service areas, note that categories of service requiring high expertise (*) are referred out 75-100% of the time.


Table 8: Services Referred out to Nonprofits by Municipality

Service Categories Groton Ledyard Montville New London Norwich Stonington Waterford Windham Number of Municipalities Referring Service to Nonprofits
Children & Families* X X X X X X X X 8
Crisis X X X X X X X 7
Food X X X X X X X X 8
Health Care* X X X X X X X 7
Housing X X X X X X 6
Employment & Income X X X X 4
Government & Legal* X X X X X X X 7
Mental Health & Addictions* X X X X X X X X 8
Older Adults X X X X X 5
Re-Entry X X X X 4
Substance Abuse* X X X X X X 6
Transportation X X X X X 5
Utility Assistance X X X X X X X 7
Volunteering X X X X 4
Youth X X X X X 5
Clothing & Household X X X X X 5
Education X X 2
Disaster X X X X 4

Source: IES municipal human service agency interviews.


When asked to list the outside agencies, typically nonprofits, that municipalities frequently contact with human services referrals, municipal agencies readily replied with those they most commonly use. Below we list the nonprofit agencies specifically identified as key resources by service area.


  • Children & Families: United Community and Family Services (UCFS), Thames Valley Council for Community Action (TVCCA), Child and Family Services (C&FS), Stonington Community Center (COMO), Safe Futures, Access Community Action Agency, Salvation Army, Catholic Charities, Windham Area Interfaith Ministry (WAIM)
  • Crisis: UCFS, Safe Futures, Salvation Army, Homeless Hospitality Center, Pawcatuck Neighborhood Center, Always Home, WARM Center, Red Cross, WAIM, Windham Region No Freeze Project
  • Food: United Way Food Pantry, St. Vincent de Paul, Covenant Soup Kitchen, First Baptist Church, Access Community Action Agency, Congressional Church, Salvation Army
  • Housing: Community Health Center, UCFS, Ledge Light Health District (LLHD), Generations Health Clinic, Windham Regional Community Council Rapid Rehousing Programs, United Services
  • Employment & Income: Opportunities Industrialization Center, Eastern Connecticut Workforce Investment Board, Renter’s Rebate Program, Willimantic American
  • Government & Legal: CT Legal Services, CT Department of Social Services, CT Department of Developmental Services
  • Older Adults: TVCCA, UCFS, C&FS, Senior Resources Agency, AAA, Pawcatuck Neighborhood Center, Westerly Adult Day Services, Hartford Healthcare Center for Healthy Aging, Nanchang Hospital Adult Program, Community Companion and Homemakers
  • Re-Entry: Opportunities Industrialization Center’s Project Employment, Catholic Charities, Fellowship House, Local Churches, Perception Programs Inc.
  • Substance Abuse: LLHD, Southeastern Regional Action Council, Community Speaks Out, Southeastern Council on Alcoholism and Drug Dependence, Stonington Institute, Sound Community Services, Generations Health Clinic, Department of Mental Health and Addiction Services, United Services, Nanchang Hospital, Community Health Resources, CT Community for Addiction
  • Transportation: Southeast Area Transit District, Eastern CT Transportation, Eastern Connecticut Transportation Consortium, Pawcatuck Neighborhood Center, Windham Regional Transit District
  • Utility Assistance: Operation Fuel, TVCCA, United Way’s Project Warm Up, Catholic Charities, Access Community Action Agency
  • Volunteering: United Way, Pawcatuck Neighborhood Center, St. Vincent de Paul, United Way, WAIM, Covenant Soup Kitchen, Windham Regional No Freeze Project
  • Youth: TVCCA, C&FS, UCFS, COMO
  • Clothing & Household: United Way, Southeast CT Furniture Bank, Salvation Army, St. Vincent de Paul, Pawcatuck Neighborhood Center, COMO, WAIM, Windham Diaper Bank
  • Education: Opportunities Industrialization Center, EASTCONN Adult Education
  • Disaster: Red Cross, Salvation Army, United Way, Community Emergency Response Teams

While the list above identifies nonprofits that municipalities most often reference when directing human services requests, there are frequently many more nonprofits offering “specialist” services in the region. Table 9 shows the number of nonprofits offering each type of service in the region according to our inventory. A more detailed review of the agencies listed above shows that municipalities are often referring out to only a handful of the largest agencies in the region. Notable big players in nonprofit service provision, which receive referrals across several categories include UCFS, TVCCA, United Way, COMO, WAIM, and Pawcatuck Neighborhood Center.


Overall Service Provision


The distribution of services by nonprofits in comparison with the types of services offered by municipalities show two distinct patterns of service. Overall, municipal human services agencies are strongest in short-term crisis services (responding to losses in heat, potential evictions, or local disasters) and case management for less acute service needs (providing programs and support services for youth, seniors, or veterans). The top five human services municipalities provide, bearing in mind the caveat that most municipal official self-reported service provision does not consider education and housing to be a human service, include: 1) Older Adults, 2) Youth, 3) Children & Families, 4) Disaster, and 5) Crisis. When it comes to those service needs requiring deep knowledge and expertise, nonprofit human services agencies step in to provide “specialist” care. The top five human services nonprofits provide, according to our inventory, include: 1) Housing and Shelter, 2) Health Care, 3) Food, 4) Mental Health and Addictions, and 5) Children & Families.


This pattern of service indeed reflects the paradigm IES proposes to describe the coordination of human services in the region—much like the health care system. Municipalities tend to act like General Practitioners serving all populations to at least some degree and stepping in as the first line of defense when more dire needs first arise. Nonprofits tend to provide specialist services that require additional expertise or licensure.






Identified Gaps in Human Service Provision in the Region


Referencing back to the 211CT unmet needs data and municipal perceptions of service gaps, almost all the top categories of unmet needs relate directly to individual poverty levels. Housing & shelter, utility assistance, and food—three of the top five unmet needs identified via 211CT data—could be solved if the client had additional monetary resources. Indeed, employment & income was the second highest unmet need in the region overall. There is no human services agency that can easily respond to the compounding effects of poverty, even though many participating municipalities and some nonprofits report having limited access to emergency cash to cover rent, utilities, or cash for short-term emergencies.


Other, more manageable, “gaps” in service balance out when health care as a metaphor for the human services network is applied. When functioning true to their designated roles, municipalities as GPs and nonprofits as specialists, several “gaps” balance out. From a nonprofit perspective, the gap might be in the following service areas where few organizations are reportedly concentrating their efforts:  re-entry, utility assistance, education, transportation, government & legal assistance, volunteering, clothing & household, or disaster. However, many of these are services are those that municipalities, even when following the Human Services Generic model, regularly arrange through their internal resources. Human services assistance via a municipality may take the form of library community classes, calls to local foundations or private donors, utility company mediation, or locally controlled transit services, among others. Additionally, some services are most frequently provided by state-level programs which were not a primary agency under analysis in this report. For example, government & legal assistance is typically referred to CT Legal Services according to municipal referral patterns.


Thus, the enigma of unmet needs despite substantial service provision in key service categories such as housing and shelter continues to be unexplained by the numbers alone. It therefore must be something about the way the health care paradigm is functioning in southeastern Connecticut that is causing this disconnect. Our interview data indicates that there are indeed two key system malfunctions, which IES asserts are the true service “gaps” in the region. The first is a lack of adequate funding, particularly from the state, for services under their jurisdiction. The second is inadequate lines of communication and cooperation between the principle actors in the human services network—namely municipalities as GPs and nonprofits as specialists. In the sections to follow, we will discuss each of these system malfunctions, or true service “gaps,” in turn.


Lack of Adequate Funding for Key Services Provided by the State


While there are several ways in which recent state funding cuts have impacted human services provision in southeastern Connecticut, detailed in the SCCOG Human Services Providers Shared Services Study, the main contributing factor to unmet service needs in the region attributable to the state is transportation. State and regional systems that control transportation are inadequate to support the existing human services ecosystem.


Our inventory of human service providers reveals that there exists a high number of the human services agencies in the two largest cities in the region. Norwich, spanning twenty-eight square miles, hosts 36 of these agencies. New London, covering an area of only six square miles, hosts 33 of these agencies. However, as is clear from the high number of calls per capita in these cities and our interviews with many of these organizations, these agencies are serving clients coming from well beyond the boundaries of their city limits.


The location of a wide range of human services organizations in only a couple of municipalities offers an opportunity for collegiality and joint planning among specialist nonprofit human services agencies. However, it can create a disproportionate burden on some city services as individuals needing services arrive or are delivered to New London and Norwich creating additional service strains on GP systems designed with the capacity and funding for residents of the municipality only. Examples of such service needs could include ambulance services to hospitals or beds in shelters overnight. New London, in fact, sees its role in human services as part of an overall economic development strategy. However, the cost and availability of transportation for these non-resident human services seekers looms as a serious and continuing gap in the effectiveness of service delivery.


It is also a disadvantage for residents scattered throughout this 692 square mile region to find their way to New London or Norwich to receive services. Nonprofit service providers, like other businesses, have a “market area” from where they draw their clients. While the market size may vary by organization, and some agencies may have multiple locations in different municipalities, there is no incentive for the nonprofits to have an office in each municipality. Thus, nonprofits tend to locate in more densely populated urban areas where most of their clientele live. Agencies may also locate in these cities because appropriate office space is available at a reasonable rate or because the cities have more friendly zoning laws. Whatever the reason, the high number of human services agencies in these two cities that provide region-wide services does result in a “municipal overburden” of service requests. This finding highlights that transportation is an important factor in the human services system, linking citizens in need of human services to municipalities hosting these specialist service providing agencies.


The map above shows many bus routes between identified “Low/Moderate Income Areas” and the locations for most of the human services provider agencies participating in our study. While the routes appear to provide sufficient coverage, further investigation reveals several transit problems:


  1. The buses are not frequent enough. It would be difficult for someone from, for example, Montville to get to an appointment in New London and home again in one day. Thus, they will need housing for the night.
  2. The bus routes completely by-pass some municipalities. While Colchester, Salem, and Lebanon, for example, are home to populations with a below average incidence of poverty, we cannot assume that residents in these communities do not have need of mental health, general health, substance abuse, disabilities, emergency shelter, or other human services. If they do, and they cannot drive their own car, they would need to use an expensive taxi service or rely on their social capital to ask a neighbor to get to and from the human services agency.
  3. It is hard to reach a bus route, even if it does go through town. The average municipality is approximately 31 square miles; if each were an actual square, it would be a distance of 5.6 miles from one side of town to the other. When the bus route is on the “other” side of town, an individual in need of human services without a car is faced with a five mile walk to wait for the bus or the same costly options described above.

Some municipal human services offices are very entrepreneurial about finding new ways to get services for their residents without the residents having to travel to the service location. A set of municipalities have sought to remedy this challenge of inaccessibility to the region’s human services agencies by attempting to attract these human services agencies to their own City or Town Hall. They offer the use of a municipal office to see residents on a weekly or bi-weekly basis, for example. This effort has met with little success. Montville’s human services director worked for years to try to get mental health professionals to come to the town to see patients for free; now the town pays the UCFS to come to the town offices one day per week to attend to clients. Waterford’s residents reportedly want to “stay in Waterford” for services according to municipal officials. The town directly finances mental health, substance abuse counselling, and case management services as a result. Other municipal human services offices, such as Groton, Montville, Stonington, Ledyard, and Windham, coordinate resident registration for state social services benefits to avoid having residents travel to the capital. This is a substantial benefit for residents. The reported wait time for a citizen calling into some state offices is 1.5 to 2 hours.


There are indeed other transit options beyond individual cars or the public system of buses. Senior centers in municipalities often have grant funded medical transportation. However, this “senior bus” is limited only to eligible seniors. Some agencies, like The Arc and Pawcatuck Neighborhood Center, have their own fleets and do provide transportation assistance to their regular clients. Some municipalities, like Stonington and Montville, pay for transit service for residents with one-time emergencies. Overall, however, the lack of routine and acceptably frequent public transit from the various corners of southeastern Connecticut to the two key locations for specialist human services is described by those we interviewed as a significant gap in the regional human services system.


Inadequate Lines of Communication and Cooperation


The topic of inadequate cooperation receives substantial attention in the SCCOG Human Services Providers Shared Services Study, and the paradigm IES has forwarded in this gap analysis of human services through the lens of the health care metaphor emphasizes the key role that communication plays in the provider network. With municipalities acting as General Practitioners and nonprofits acting as specialists, there must be a strong referral system between the two. Unfortunately, however, nonprofits and municipalities are not always collaborating in the region. In fact, as we state in our corollary study, they are sometimes pitted against one another as competitors for limited sources of funding. On a case by case basis, municipalities and nonprofits have learned to work together. However, there are no standard patterns or models for approaching coordination. It is vitally important that these key actors in the human service ecosystem recognize their innate interdependencies, the smooth integration of which is necessary to fulfill the region’s human service needs.


In demonstration of this point, the very system designed to facilitate referrals—211CT—is inadequately shouldering this role. The 211CT database sponsored by the United Way of Connecticut launched only quite recently, in 2014, to enable people in need of services to find those services by calling in for a referral. This system will be a critically important policy planning tool, as well as a support for individual citizens in need.  But it is not there yet.


Indeed, data collected by 211CT is presently insufficient to clearly determine specific gaps in services. As shared above, IES noted that 17 of the 37 agencies participating in this study (46%) were not even listed in the 211CT database. IES was therefore compelled to generate a more comprehensive list of human services providers in the region, which combined the organizations registered in the 211CT database and the SCCOG-produced Southeastern Connecticut Regional Human Services Directory, to conduct this study. Nine of the fifteen major service categories in the 211CT database, including Children & Families, Employment, Government & Legal, Mental Health & Addictions, Older Adults, Re-Entry, Substance Abuse, Transportation, and Utility Assistance have two or fewer associated service providers listed.  Only Crisis, Food, Health Care, and Housing & Shelter, less than 25% of the categories, have a significant number of listings. Because of this low level of participation in the database system, any assessment of unmet need using 211CT data may be skewed to over-represent those categories with few listings in 211CT. Why so few listings? According to 211CT staff, listings are supposed to be submitted by the human services agencies and then verified by 211CT. But agencies are not submitting their services to 211CT for inclusion in the database. It appears that key players in the region’s human services ecosystem have not yet been convinced of the value of submitting their services lists to 211CT.


Additionally, the current categorization used to classify services is so broad, high level, and generic that true gaps in the continuum of care for residents of the region are not possible to identify. To be more relevant to human services agencies and policy makers, the “unmet needs” results need to be both easier to obtain and more relevant for identifying specific service gaps. The fifteen core categories are so broad that searching for unmet needs by these “level 1” categories is almost meaningless. 211CT has developed up to three or four levels of sub-categories for each major category. For example, the main category Mental Health & Addictions covers the following sub-categories:


  • Crisis Intervention, Suicide
  • Mental Health Services
  • Substance Abuse & Addictions

However, these subcategories do not collapse easily; so, finding the “unmet needs” counts for these sub-categories, comparing them to several total requests per sub-category, and developing a percentage that should, in theory, represent a gap in services, is extremely difficult. Furthermore, the categories and sub-categories are not intuitively obvious, nor are they mutually exclusive. In summary, the data is hard to manage. Beyond the United Way 211CT service categories, which we have now established are poorly defined and clunky, there is no taxonomy of services that is in general use across the region for defining human services.


Finally, some of the more superficial complaints about 211CT are that calling in by phone takes too long, callers are left on hold, or referrals too often lead to dead ends. Some citizens find that municipal human services staff are more likely to offer quality referrals or make personal introductions than can be achieved via the 211CT system that is meant to take on this role. The IES study team believes that much of the dissatisfaction with the current 211CT process can be labeled as a case of “growing pains” for a new digital information system. Additional investments in time, money, technology, and outreach to providers should be made.


To conclude, communication is vital to the success of a system that very much operates like a health care network based on referrals among “generalists” and “specialists.” Without strong lines of communication between municipalities and nonprofits, the main actors in this system, and an incomplete 211CT database of services, resident needs will continue to go unmet. Working to improve collaboration across the human services provider network and to increase the participation rates, service definition clarity, and usability of 211CT would greatly improve the human services ecosystem. Addressing this gap will facilitate the crucial connection between key service providers in the region.






Challenges and Limitations of the Gap Analysis


In this report, IES identified the current human services models employed by municipalities in the region with a defined human services capacity. For those municipalities that do not have a defined human services capacity, we will provide a recommended model in the subsequent section. We have also endeavored to compare service needs and unmet needs with services provided by municipality. However, several challenges and limitations intervened which did not allow us to provide a simple list of services missing from each of the region’s communities. These challenges fall into three categories.


First, a point discussed previously with regards to the 211CT data, there is no available list of service providers or consistent categorization in use for classifying service types in the region. Without a clear definition of a human services agency, a definitive list of agencies beyond that we have generated ourselves, or, most importantly, data on the services provided by all agencies in the region, it is impossible to do a direct comparison of the ideal service profile with the data on services available. Our best technical resource for analysis, the 211CT database, excluded 46% of the organizations participating in the study. Additionally, when cross-referencing our interview data with those that were included in the 211CT database, many of the separate services each of these organizations provide were not listed. While there may indeed be gaps in specific services, the major obstacle to identifying and filling in gaps in services is poor data. To overcome this challenge, the IES study team has triangulated three key data sources—CERC, 211CT, and interview data—to compare service needs with patterns of service among municipalities and nonprofit agencies.


Second, upon triangulating data sources, there appeared to be no definitive evidence of a gap in services. Service providers in the region do indeed provide human services that address the all the top requested service categories and in the most socio-economically disadvantaged geographies according to the CERC and 211CT caller data. Thus, we determined that the data must be overlooking key factors, such as good public transportation or a full inventory of service providers, standing between the network of human services providers and the citizens of the region in need of those services. This discovery led the IES team to explore new, and more nuanced, reasons for the high level of unmet service needs reported by 211CT in key areas, most notably in the category of housing & shelter services. Along these lines, we explored key service provision factors that are missed in an exercise of “big data” analysis. These factors included a lack of state funding for key services and infrastructure like public transportation, and an inadequate and inconsistent system of service coordination between municipalities and nonprofits.


Third, both municipalities and nonprofits have a level of independence and fluidity that make a recommended service profile impossible to develop and obsolete. Municipalities have a variety of factors that shape their willingness to address certain human services needs and opportunities, including the culture of that community, the agenda of the current elected officials in office, and the capacity of the municipality to establish a staff to coordinate services, assuming that they even wish to address “human services” at all. These factors can vary from year to year within a municipality.  A similar scenario is true of nonprofit agencies. Nonprofit agencies are private corporations, governed by a private board of directors. These agencies have their own business models, business plans, competitive advantage, and strategies for achieving their missions.

The IES study team can therefore only infer, versus compel, an agency’s capacity and interest in following-through on study recommendations.


Given these limitations, the next section turns to our recommendations based on the two key gaps identified through this analysis.



Due to inadequate data to appropriately determine where gaps exist in human services provision in southeastern Connecticut, it has been necessary to set aside hopes and assumptions associated with “big data” analyses and dig deeper to identify the real “gaps” in the service ecosystem for those most in need in the region. Where gaps do exist, they fall into two categories. In this section, we will briefly review each gap and offer recommendations for how to close them.


First, gaps exist as a function of a lack of support for human services in state policy and funding. While state funding for human services has decreased greatly since the repression (see SCCOG Human Services Providers Shared Services Study for details), a lack of funding for appropriate transportation between service nodes in cities has caused a service gap in the region. The frequency and spread of transit routes are the key barriers to travel currently. Thus, IES concludes that state and regional systems that control transportation are inadequate to support the existing human services ecosystem. When key systems are inadequate, particularly those that serve populations across municipal boundaries, the burden of caring for affected citizens falls to local nonprofits and municipalities.


More state funding is needed for human services and fundamental infrastructure in the region. IES suggests that the region approach this task through a “Pay for Success” model. Pay for Success pushes funding toward innovative programs that can prove their success with impact data over time. This model requires that networks of providers work together to demonstrate scalable impact capacity with regional and national foundations. The institution of such a model in the region would both bring in new funding and incentivize collaborative partnerships amongst providers to improve service outcomes.


Second, pathways for information, communication, and cooperation between human services providers in the region are insufficient or misaligned. 211CT was devised to help overcome the communication gap between residents and human services providers by streamlining the referral process from an individual in need to the appropriate provider. However, 211CT is not very approachable for resident users, it does not have a sufficient participation rate in the region by service providers, and definitions of services in 211CT are too broad, unclear, and complex due to layering within the database.


To be more relevant to residents, the 211CT system should be available as a mobile application and should enable the user to set a location radius and key word search for services within that radius. The application should also employ low-level artificial intelligence so that, over time, it learns key search terms, results, and click-throughs to improve usability and offer a set of related resources by request. For example, if an individual searches for employment, that person would also be provided with a set of tools such as job search databases, re-entry training programs, or legal support in cases of discrimination. For policy-makers, 211CT should make its service categories collapsible so that the data is easier to manage and analyze. For all stakeholders, a concerted effort should be made to increase provider participation rates.


Additional communication paths and systems are needed to fulfill this key link between providers in the region. A preliminary step toward overcoming this challenge is to make it worthwhile for service providers to share information about their services in the form of shared data, clients, facilities, expertise, and funding sources. The key here is to make communication between key stakeholders “risk free,” or to take it one step further, incentivized. The proximate step is to develop a clearer categorization of human services needed and delivered in the region. This new set of categories should reflect the dimensions of short-term human services and long-term care services as well as services best coordinated by municipal GPs versus nonprofit specialists requiring clinical and professional expertise. Rather than dismiss the utility of 211CT data completely, IES suggests that providers work collaboratively with United Way to contribute searchable information and refine database categories so that this important resource is more useful to citizens seeking help and policymakers interested in targeting interventions toward unmet needs.


Service providers should also look to build upon best practices in service coordination in the region. This process will look different for providers depending on type and role in the service model paradigm we have forwarded throughout this report. We will discuss our recommendations for municipalities as general practitioners first, and then turn to the example of one nonprofit capitalizing on their specialist role.


For municipalities, we recommend that those municipalities without a human service capacity consider right-sizing the service models for their communities’ needs per the guidelines below.


Socio-economically advantaged towns with populations over 10,000:

Colchester, East Lyme, Salem


These communities do not present clear indicators associated with high levels of human service needs, but they each have recorded unmet needs in the 211CT database. At minimum, informally consolidating and coordinating existing human services capacities will signal to residents that the municipality has a pro-active plan for addressing their needs. IES recommends that these municipalities transition from a “Human Services Officer” to a “Human Services Department” model over a period of years.


These efforts would come at little to no cost. Given that these municipalities are large, they likely have at least one staff person overseeing the Senior Center, Youth Services, Recreation, or Veterans Affairs. To begin to consolidate efforts, they should convene periodic meetings amongst these key staff. They can then add in representatives from Police, Fire, Inspectional Services, and the Library in phase 2, and invite representatives from local nonprofits, public health officials, and foundations in phase 3.  Municipalities looking to make this shift can call upon the Connecticut Conference of Municipalities or the Connecticut Youth Services Association to advise; they should also look to the best practices of Groton, Montville, Norwich, Stonington, Waterford, or Windham that currently have a Human Services Department.


Socio-economically advantaged towns with populations under 10,000:

Bozrah, Franklin, Lebanon, Lisbon, North Stonington


Smaller municipalities, with populations between 3-7,000 in southeastern Connecticut, can maintain robust service delivery operating with a culture of volunteerism. They are likely to have a Library, Recreation Program, and Senior Center.  They are also likely to have religious organizations actively involved in charitable volunteer work for the community. IES recommends that these municipalities move toward a designated “Human Services Officer” model.


This shift can begin by holding meetings with the above representatives, as well as Fire Emergency Services, local utilities, and any local nonprofits or private sector entities with a track-record of community support. These meetings should be convened with the goal of discussing the needs of the community and increasing cooperation among these local resources. For services unavailable locally, they should utilize resources such as 211CT to look up services outside of town but still available for local citizens.  As local coordination improves, these towns should consider contracting with the Norwich Department of Human Services to advise, support, and increase local municipal capacity.


Socio-economically disadvantaged towns of all population sizes:

Griswold, Preston, Sprague


For towns that are currently managing high levels of socio-economic disadvantage (as measured by high poverty levels, low educational achievement, and median incomes below the state/regional average), each should focus their capacity toward greater internal coordination, first around the “Human Services Generic Services” model and then moving toward a designated “Human Services Officer” model.


Given that these towns have a greater level of need for human services, it is vitally important that they identify someone who can be the recipient of information and resources for human services on behalf of the Town.  These municipalities should begin by taking stock of services that currently exist in the area and then contract with a Human Services Department like those in Norwich or Windham to clarify and develop their internal human services operations. Given their current level of need, a coordinated effort by any one of these municipalities would make the local government a strong candidate for foundation funding. Coordinating access to their services could be a great benefit to the socio-economically disadvantaged populations in these communities.


For nonprofits, the best way to serve the community is to leverage their specialist skills. One of the most effective service delivery systems by a nonprofit that we encountered was evolving during the time of the study. In this case, the region adopted a policy of avoiding shelter placements, referred to as “shelter diversion” or “rapid re-housing.” Via this policy, all shelter beds were filled through one referral source: TVCCA. The value of this approach to fulfill the need for housing and shelter, which IES identified as the greatest area of need in the region, was that it put pressure on all service providers in the housing and shelter continuum of care to find a solution to the problem before opting for the solution of last resort (i.e. finding a temporary shelter bed). Thus, fewer residents would lose their current housing status. It also streamlined the placement process by making all parties aware of the available service options and ensuring each referral was prioritized equally. A uniform policy across the region, focusing on a top priority service need, is one way to close the gaps in information and communication among human services organizations.


If municipalities can achieve the goal of right-sizing their human services capacity based on their socio-economic profiles as IES has recommended, they will be able to more effectively perform the function of human services General Practitioners. Likewise, if nonprofits can focus their efforts on top-quality specialist care in areas of greatest need in the region, they will be able to expand their reach and advance their missions all the while improving service to the regions’ residents.



Appendix #1:


Service Category Service Request # of Unmet Requests
Housing & Shelter Rent assistance 837
Employment & Income Financial assistance 578
Housing & Shelter Shelters 422
Utilities Electric 134
Mental Health & Addictions Crisis intervention & suicide 105
Other All other requests 82
Food Food pantries 51
Government & Legal Contacts 46
Housing & Shelter Low-cost housing 42
Disaster Housing/ shelter 41
Healthcare Health insurance 37
Food Soup kitchens 36
Mental Health & Addictions Substance abuse & addictions 36
Mental Health & Addictions Mental health services 34
Housing & Shelter Contacts 30
Clothing & Household Clothing 29
Other Support & advocacy 19
Utilities Heating fuel 19
Clothing & Household Seasonal/ holiday 19
Disaster Other disaster 17
Other Complaints 16
Housing & Shelter Landlord/ tenant issues 16
Government & Legal Legal assistance 16
Healthcare Nursing homes & adult care 15
Transportation Assistance Public transportation 15
Government & Legal Child & family law 14
Food Holiday meals 13
Food Help buying food 13
Employment & Income Contacts 12
Other Volunteering & donations 11
Utilities Gas 11
Employment & Income Job search 10
Transportation Assistance Other transportation assistance 10
Healthcare Medical providers 9
Utilities Water 8
Transportation Assistance Medical transportation 8
Employment & Income Tax preparation 7
Housing & Shelter Mortgage assistance 6
Other Community development & enrichment 6
Government & Legal Government 6
Mental Health & Addictions Mental health facilities 5
Clothing & Household Other clothing & household 5
Transportation Assistance Automobile assistance 5
Utilities Disconnection protection 5
Housing & Shelter Home repair/ maintenance 5
Child Care & Parenting Child care 5
Healthcare Contacts 4
Food Home-delivered meals 3
Clothing & Household Appliances 3
Education School supplies 3
Utilities Contacts 3
Healthcare Medical expense assistance 3
Healthcare Dental care 2
Healthcare Medical equipment 2
Education ESL/ citizenship 2
Healthcare Other health services 2
Utilities Phone 2
Education Other education providers 1
Healthcare Prescription medications 1
Utilities Utility payment plans 1
Healthcare Reproductive health 1
Employment & Income Money management 1
Clothing & Household Home furnishings 1
Clothing & Household Thrift shops 1
Education Scholarships & aid 1
Government & Legal Immigration assistance 1
Healthcare Eye care 1

Source: United Way of Connecticut. (2018). 211CT. Retrieved from


Appendix #2:



Human Services Agency City Type Service
ACCESS COMMUNITY ACTION AGENCY* Willimantic (Windham) Nonprofit   Food, Housing & Shelter, Employment & Income
AHEPA 110-II APARTMENTS 🔹 Norwich Municipal Housing & Shelter
AHEPA 250-III APARTMENTS 🔹 Groton Municipal Housing & Shelter
ALLIANCE FOR LIVING*🔹 New London Nonprofit Food, Health Care, Housing & Shelter
ALWAYS HOME* Mystic (Groton) Nonprofit Children & Families, Housing & Shelter, Employment & Income, Transportation, Utility Assistance
ALZHEIMER’S ASSOCIATION🔹 Norwich Nonprofit Health Care
AMERICAN JOB CENTERS AFFILIATE 🔹 Willimantic (Windham) State Employment
BARKAN MANAGEMENT 🔹 Norwich Private Housing & Shelter
BAYVIEW HEALTH CARE CENTER🔹 Waterford Nonprofit Health Care
BETHSAIDA COMMUNITY, INC.*🔹 Norwich Nonprofit Housing & Shelter, Mental Health & Addictions, Substance Abuse
BOZRAH (TOWN OF)🔹 Bozrah Municipal Food
CARABETTA MANAGEMENT 🔹 New London Private Housing & Shelter
CARECO MEDICAL, INC.🔹 New London Private Health Care
CATHOLIC CHARITIES, DIOCESE OF NORWICH*🔹 Norwich Nonprofit Crisis, Food, Mental Health & Addictions, Utility Assistance, Clothing & Household
CENTER FOR HOSPICE CARE, SE CT Norwich Nonprofit Older Adults, Health Care
CENTRO DE LA COMUNIDAD🔹 New London Nonprofit Food
CHILD AND FAMILY AGENCY OF SE CT New London Nonprofit Children & Families
COLCHESTER (TOWN OF) DEPT OF YOUTH/SOCIAL SERVICES Colchester Municipal Children & Families, Youth, Substance Abuse, Food, Utility Assistance
COMMUNITY HEALTH CARE CENTER New London Nonprofit Health Care
COVENANT SHELTER* New London Nonprofit Children & Families, Housing & Shelter, Other
CRISIS PREGNANCY CENTER🔹 Unionville Nonprofit Crisis
DEMARCO MANAGEMENT 🔹 New London Nonprofit Housing & Shelter
ELDERLY HOUSING MANAGEMENT 🔹 Waterford Nonprofit Housing & Shelter
FHM SERVICES – FELLOWSHIP HOUSE🔹 Groton Nonprofit Housing & Shelter
GENERATIONS FAMILY HEALTH CARE CENTER* Willimantic (Windham) Nonprofit Health Care, Mental Health & Addictions, Substance Abuse
GRISWOLD (TOWN OF) DEPT OF YOUTH & FAMILY SERVICES Jewett City (Griswold) Municipal Youth, Children & Families
GRISWOLD (TOWN OF) HOUSING AUTHORITY 🔹 Jewett City (Griswold) Municipal Housing & Shelter
GROTON (TOWN OF) DEPT OF HUMAN SERVICES*🔹 Groton Municipal Food, Crisis, Children & Families, Older Adults, Utility Assistance, Youth, Volunteers, Mental Health & Addictions, Clothing & Household, Education, Employment & Income, Substance Abuse, Government & Legal Assistance, Transportation, Re-Entry, Other
GROTON (TOWN OF) HOUSING AUTHORITY 🔹 Groton Municipal Housing & Shelter
GUIDE🔹 Norwich Nonprofit Disabled Services, Youth
HABITAT FOR HUMANITY OF EASTERN CONNECTICUT HOUSING* New London Nonprofit Housing & Shelter, Employment & Income, Volunteering, Government & Legal
KONOVER RESIDENTIAL CORPORATION 🔹 Norwich Private Housing & Shelter
LEDYARD (TOWN OF) DEPARTMENT OF HEALTH CARE & HUMAN SERVICES*🔹 Ledyard Municipal Food, Disaster, Children & Families, Youth, Older Adults, Utility Assistance, Health Care, Clothing & Household
LEDYARD (TOWN OF) HOUSING AUTHORITY / KINGS CORNER MANOR🔹 Gales Ferry (Ledyard) Municipal Housing & Shelter
LIGHT HOUSE, THE 🔹 Groton Nonprofit Housing & Shelter,  Disabled Services
MADONNA PLACE*🔹 Norwich Nonprofit Children & Families,  Housing & Shelter
MARTIN HOUSE, INC.*🔹 Norwich Nonprofit Food, Housing & Shelter, Health Care, Mental Health & Addictions, Substance Abuse
MASONICARE HOME HEALTH CARE & HOSPICE🔹 Mystic (Groton) Nonprofit Health Care
MOHEGAN TRIBAL COUNCIL HEALTH CARE & HUMAN SERVICES* Uncasville Tribal Nation Health Care, Children & Families, Older Adults
MOHICAN SENIOR APARTMENTS🔹 New London Nonprofit Housing & Shelter, Disabled Services
MONTVILLE (TOWN OF) DEPT OF SENIOR & SOCIAL SERVICES*🔹 Uncasville (Montville) Municipal Food, Crisis, Children & Families, Older Adults, Utility Assistance, Health Care, Youth, Volunteers, Mental Health & Addictions, Clothing & Household, Education
MONTVILLE (TOWN OF) HOUSING AUTHORITY 🔹 Uncasville (Montville) Municipal Housing & Shelter
MONTVILLE HOUSING AUTHORITY 🔹 Oakdale (Montville) Municipal Housing & Shelter
MYSTIC AREA SHELTER & HOSPITALITY, INC. Mystic (Groton) Nonprofit Housing & Shelter
NATCHAUG HOSPITAL*🔹 Mansfield Nonprofit Health Care, Mental Health & Addictions, Substance Abuse
NEW BEGINNING RECOVERY HOUSES 🔹 New London Nonprofit Housing & Shelter
NEW LONDON (CITY OF) DEPT OF HUMAN SERVICES*🔹 New London Municipal Children & Families, Youth, Older Adults, Disaster, Volunteers, Education
NEW LONDON (CITY OF) HOUSING AUTHORITY🔹 New London Municipal Housing & Shelter, Food
NEW LONDON AREA FOOD PANTRY🔹 New London Nonprofit Food
NEW LONDON HOMELESS HOSPITALITY CENTER* New London Nonprofit Housing & Shelter, Mental Health & Addictions, Substance Abuse, Re-Entry
NOANK COMMUNITY SUPPORT SERVICES🔹 Groton Nonprofit Housing & Shelter
NORWICH (CITY OF) DEPT OF HUMAN SERVICES*🔹 Norwich Municipal Food, Crisis, Children & Families, Older Adults, Utility Assistance, Health Care, Youth, Volunteers, Mental Health & Addictions, Clothing & Household, Education, Employment & Income, Substance Abuse, Government & Legal Assistance, Transportation, Re-Entry
NORWICH (CITY OF) HOUSING AUTHORITY🔹 Norwich Municipal Housing & Shelter
NORWICH (CITY OF) YOUTH AND FAMILY SERVICES🔹 Norwich Municipal Youth, Children & Families, Mental Health
PARADISE AGENCY 🔹 Jewett City (Griswold) Nonprofit Housing & Shelter
PAWCATUCK NEIGHBORHOOD CENTER Pawcatuck (Stonington) Nonprofit Older Adults, Transportation, Crisis, Utility Assistance
POQUONNOCK VILLAGE🔹 Groton Nonprofit Housing & Shelter
PRESTON (TOWN OF) Preston Municipal Older Adults, Children & Families
RELIANCE HOUSE, INC.*🔹 Norwich Nonprofit Health Care, Mental Health & Addictions, Substance Abuse, Housing & Shelter, Employment & Income
SAFE FUTURES 🔹 New London Nonprofit Housing & Shelter
SAINT MARY’S CHURCH FOOD PANTRY🔹 Jewett City (Griswold) Nonprofit Food
SALVATION ARMY OF SOUTHEASTERN NEW ENGLAND*🔹 New London Nonprofit Crisis, Employment & Income, Clothing & Household, Food, Mental Health & Additions, Substance Abuse
SENIOR RESOURCES AGENCY OF AGING* Norwich Nonprofit Older Adults
SK MANAGEMENT 🔹 Jewett City (Griswold) Private Housing & Shelter
SOUND COMMUNITY SERVICES, INC.*🔹 New London Nonprofit Health Care, Housing & Shelter, Mental Health & Addictions
SOUTHEASTERN COUNCIL ON ALCOHOLISM AND DRUG DEPENDANCE*🔹 Lebanon Nonprofit Mental Health & Addictions, Substance Abuse, Re-Entry
SPRAGUE HOUSING AUTHORITY 🔹 Sprague Municipal Housing & Shelter, Disabled Services, Older Adults
ST. VINCENT DE PAUL PLACE*🔹 Norwich Nonprofit Food, Clothing & Household, Volunteering
STONINGTON (TOWN OF) DEPARTMENT OF HUMAN SERVICES*🔹 Pawcatuck (Stonington) Municipal Food, Crisis, Children & Families, Older Adults, Utility Assistance, Youth, Volunteers, Mental Health & Addictions, Education, Employment & Income, Substance Abuse
SUMMITWOODS / SUMMITWOODS II🔹 Norwich Nonprofit Housing & Shelter
SUPERIOR COURT, CONNECTICUT – NEW LONDON🔹 New London State Legal & Governmental, Housing & Shelter
THAMES RIVER COMMUNITY SERVICE, INC.*🔹 Norwich Nonprofit Housing & Shelter, Mental Health
THAMES VALLEY COUNCIL FOR COMMUNITY ACTION, INC.*🔹 Jewett City (Griswold) Nonprofit Housing & Shelter, Children & Families, Utility Assistance, Education
THE ARC NEW LONDON COUNTY* Norwich Nonprofit Housing & Shelter, Employment & Income, Transportation, Youth
THE CENTER: A DROP-IN COMMUNITY New London Nonprofit Children & Families
THE CONNECTION, INC.*🔹 Middletown Nonprofit Children & Families, Housing & Shelter, Substance Abuse, Mental Health & Addictions, Re-Entry
THE RIVERFRONT CHILDREN’S CENTER, INC.* Groton Nonprofit Children & Families, Education
UNITED CEREBRAL PALSY OF EASTERN CT Quaker Hill (Waterford) Nonprofit Disabled Services
UNITED COMMUNITY AND FAMILY SERVICES*🔹 Norwich Nonprofit Crisis, Health Care, Youth, Children & Families, Mental Health
UNITED SERVICES🔹 Willimantic (Windham) Nonprofit Health Care
UNITED WAY OF CONNECTICUT, 2-1-1*🔹 Rocky Hill Nonprofit Other, Employment
UNITED WAY OF SOUTHEASTERN CT*🔹 New London Nonprofit Food, Older Adults
UTOPIA HOME CARE🔹 New London Nonprofit Health Care
VESTA CORPORATION 🔹 Norwich Private Housing & Shelter
VILLAGE COURT🔹 Norwich Nonprofit Housing & Shelter
VISITING NURSE ASSOC. OF SE CT🔹 Waterford Nonprofit Health Care
WATERFORD (TOWN OF) YOUTH SERVICE BUREAU* Waterford Municipal Food, Crisis, Children & Families, Older Adults, Utility Assistance, Youth, Volunteers, Mental Health & Addictions, Clothing & Household, Education, Substance Abuse, Transportation
WEQUONNOC VILLAGE🔹 Norwich Private Housing & Shelter
WHOLE LIFE, INC.* New London Nonprofit Health Care
WILDWOOD PROPERTY MANAGEMENT 🔹 Norwich Nonprofit Housing & Shelter
WINDHAM (TOWN OF) DEPT OF HUMAN SERVICES* Willimantic (Windham) Municipal Crisis, Disaster, Employment & Income, Government & Legal Assistance, Education, Youth, Older Adults, Other
WINDHAM COMMUNITY MEMORIAL HOSPITAL – FIND A DOCTOR🔹 Willimantic (Windham) Nonprofit Health Care
WINDHAM REGIONAL COMMUNITY COUNCIL, INC.* Willimantic (Windham) Nonprofit Health Care, Children & Families, Youth, Housing & Shelter
WINNRESIDENTIAL 🔹 Norwich Private Housing & Shelter
Key: *SCCOG Study Participating Agency, 🔹 Listed in 211CT


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