Policy and Practice | June 2022

The Magazine of the American Public Human Services

Association June 2022

Shifting Power to People and Place What It Takes to Drive System Change

TODAY’S EXPERTISE FOR TOMORROW’S SOLUTIONS

www.aphsa.org

contents

Vol. 80, No. 3 June 2022

features

6

10

Breaking Down Barriers How Agencies Are Connecting Caseworkers, Clients, and Providers

Elevating the Human Experience A More Responsive, Seamless, and Effective Health and Human Services System

14

18

Driving Better Outcomes Person-Centered, Equity-Focused, and Data-Driven Systems

Healing Policy Papercuts How Aligning Conflicts in Application Requirements Makes Benefits Easier to Access

departments

3 President’s Memo

23 From Our Partners

Shifting Power to People to Unlock the Assets of Families and Communities

Putting People First: Transforming Agencies with Human-Centered Design

5 From the Field TANF Agencies’ Critique and Aspirations for the Future 22 Research Corner Life After TANF: A Survey of Former Program Enrollees

28 Staff Spotlight

Nina Darby, Human Resources Specialist

1

June 2022 Policy&Practice

Strategic Industry Partners

APHSA Executive Governing Board

Chair Dannette R. Smith, CEO, Nebraska Department of Health and Human Services Vice Chair Rodney Adams, Former Director, Mecklenburg County (NC) Department of Community Resources Immediate Past Chair David A. Hansell, Former Commissioner, NewYork City Administration for Children’s Services Treasurer Reiko Osaki, President and Founder, Ikaso Consulting Elected Director Derrik Anderson, Executive Director, Race Matters for Juvenile Justice Elected Director Vannessa L. Dorantes, Commissioner, Connecticut Department of Children and Families

Elected Director Kathy Park, CEO, Evident Change Elected Director

DIAMOND

Terry J. Stigdon , Agency Head/Executive Director, Indiana Department of Child Services Elected Director Jennifer Sullivan , Senior Vice President for Strategic Operations, Atrium Health Elected Director Eboni Washington , Assistant Director, Clark County (NV) Juvenile Justice Services Leadership Council Representative Justin Brown, Director, Oklahoma Department of Human Services Local Council Representative Antonia Jiménez , Director, Los Angeles County Department of Public Social Services

PLATINUM

SILVER

2

Policy&Practice June 2022

president‘smemo By Tracy Wareing Evans

Shifting Power to People to Unlock the Assets of Families and Communities

I n this column, I share the second part of my own reflections on what struc tural power is and what it means to system leaders aiming to center com munities in delivery of their agency mission. It is at the heart of the theme of this month’s issue: Shifting Power to People and Communities: What It Takes to Drive System Change. A key to achieving this objective is shifting how we work . For the power dynamics to change, we have to show up differently than we have before. It begins with building authentic rela tionships with community leaders, not just in the occasional stakeholder meeting, but by getting out into com munities at the table set by the people who live there. As we enter each community, we have to respect its uniqueness, seek to understand its history, and value its strengths. Focusing on the assets of family and community is not new to human services leaders. Nor is the concept of designing systems and service delivery from the perspective of the end user. And, yet, if we are being honest with ourselves, we knowwe are far from achieving a human-centered, commu

whole family approaches, trauma informed care, and social determinants of health, we have gained critical insights into how our institutions and systems work—both their potential for good, and the inherent and cumulative harmwe are obligated to undo. Put another way, the lens of these orienta tions has helped us, as human services leaders, see more clearly that people and communities are too often held in place by the very systems and structures we run. Our imperative is to learn how to use our positional power to remove that structural hold. This is at the heart of leadership today. We must resist the temptation to pass off relation ship-building and engagement with community stakeholders as “nice to

fosters authentic engagement in service of people. And, contextually, the public institutions in which we aim to do good are themselves a historical vehicle of systemic racism and structural bias. Recognizing our part in generating inequitable systems that stymie the inherent power of people is a first step to truly being able to shift structural power and help unlock the assets of families and communities. A colleague recently described what we need to do as “radically disrupting the current system” through a human-centered lens that “sees people as experts and whole.” This disruption is more than a shift in policy or practice, it requires a new mental model that shifts the paradigm of how government itself, including human services, interacts with people and communities. In many ways, leaders of public human services agencies have been on this path for some time. Through the applied lens of the Human Services Value Curve, as well as

See President’s Memo on page 24

nity-led system of care. We work within systems and structures

that are rules based and constrained, fueling a culture of compliance instead of one that

Image via Shutterstock

3

June 2022 Policy&Practice

Vol. 80, No. 3

www.aphsa.org

Policy & Practice™ (ISSN 1942-6828) is published six times a year by the American Public Human Services Association, 1300 N. 17th Street, Suite 340, Arlington, VA 22209. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2022. All rights reserved. This magazine may not be reproduced in whole or in part without written permission from the publisher. The viewpoints expressed in contributors’ materials are the authors’ own and do not necessarily reflect the policies or views of APHSA. Postmaster: Send address changes to Policy & Practice 1300 N. 17th Street, Suite 340, Arlington, VA 22209

Advertising Anna Nogueira ads_exhibits@aphsa.org

President & CEO Tracy Wareing Evans Communications Director/Editor- in-Chief Jessica Garon jgaron@aphsa.org

Subscriptions Max Daniel mdaniel@aphsa.org

Design & Production Chris Campbell

Editor Amy Plotnick

2 0 2 2 Ad v e r t i s i n g C a l e n d a r

Issue

Ad Deadline

Issue Theme

August October December

July 1

Navigating Upstream: Achieving Better Health and Well-Being Through Prevention Innovating for the Future: Maximizing Modern Tools and Platforms

August 26 October 21

Partnering for Impact: Co-Creating Generative Solutions

Size and Placement Two-page center spread: Back Cover (Cover 4): Inside Back Cover (Cover 3): Inside Front Cover (Cover 2):

Rate

Discount for 6 Consecutive Issues

$8,000 $6,000 $5,400 $5,400 $3,000 $1,200 $1,050

$7,200/issue $5,400/issue $4,860/issue $4,860/issue $2,700/issue $1,080/issue $945/issue

Full page:

Half page, horizontal: One-third page, vertical:

4

Policy&Practice June 2022

from the field By Babette Roberts

TANF Agencies’ Critique and Aspirations for the Future

T emporary Assistance for Needy Families (TANF) is important—it provides millions of parents and care givers with the economic supports to help them meet their basic needs; employment and training skills to earn family-sustaining wages; early child hood care that fosters development during children’s formative years; and services that prevent and mitigate childhood stress and trauma. TANF was established more than 25 years ago with the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Since then, we have learned a lot about what works—and what does not—to create communities where everyone has an opportunity for economic mobility and the tools to support the physical, social, and emotional well-being of our families. However, in the last 25 years, the structure of the TANF program has remained largely unchanged. While TANF’s structure as a block grant gives states broad flexibility, federal law sets forth a policy framework that shapes the way state and local agencies design and implement their programming. The current federal framework for TANF emphasizes work requirements, time limits and penalties, and incen tive structures that reward reductions in the number of families receiving assistance regardless of progress in helping them achieve family sustaining wages. In fact, the last reauthoriza tion of TANF, in 2005, reinforced an emphasis on work compliance and verification, which actually reduced states’ ability to leverage the flexibility built into the law.

n Work requirements have been a core tenet of TANF since its incep tion and are set up as a condition for receipt of cash assistance. They must be fulfilled through employment and training activities, are time limited, prioritize immediate work over longer-term career opportunities and family development, and require close monitoring for compliance. n Required lifetime limits cut off assistance regardless of a family’s success in transitioning to living wage employment and the structural and historic barriers that may have made that transition more difficult for some families than others.

n Performance metrics, and the penalty and incentive structures that frame them, reward reduc tions in the number of families receiving assistance regardless of whether progress is made in helping them achieve living wage jobs and encourage sanctioning families who are unable to meet strict compliance with program requirements. This policy landscape diminishes the reach of TANF over time. Indeed, for every 100 families in poverty, the number receiving TANF basic

See TANF Future on page 25

Illustration by Chris Campbell

5

June 2022 Policy&Practice

BAR RIERS BREA KING DOWN Breaking Down Barriers: How Agencies Are Connecting Caseworkers, Clients, and Providers

By Laura Haffield and Lauren Hirka

O

ne of a social worker’s most important responsibilities is collecting and dissemi nating critical information to make life-altering decisions in a timely manner. Schools, courts, hospitals, placement providers, treatment providers, advocacy centers, and most important, clients and families—the list of organizations and individuals outside the agency that might provide this critical information is lengthy. Yet the processes in place for sharing it have historically been complicated and counterproductive. Today, the tides are turning. The industry is embracing more flexible work practices. Modernization efforts encourage collaboration, especially sharing data and information about the mutual clients we all serve. Technology is becoming available to help reduce friction and facilitate more meaningful collaboration across programs and people, both inside and outside of the agency. But there is also a catch because not just any technology will do. Human services leaders have long cried out for tools that are truly built from their perspective and around the needs of those they serve. The time is now to bring this vision to life.

Current Limitations Let us use the common task of a worker obtaining a child’s medical records to put the challenges with manual methods of collaboration and client engagement into perspective. Can you spot the hurdles? n First, I need to get consent from the child’s caregiver for these pro tected records to be released to me. I drive to her home at our scheduled meeting time, hoping it works. If not, I cannot come back until next week. n I need her to sign a release of informa tion that the provider who maintains the medical records will accept. If I use the wrong version of the form, I will have to start from scratch. n Once I have gotten the signature, I need to drive back to my home office and double check the submis sion process for this provider. It says to scan and email the document, so I do. And then I wait. I start to wonder—did I check all the right boxes? Did I use the right form? n Finally, I hear from the office that the provider is sending the records to the agency. I drive there to look at them so I can finally start the decision making process. Despite best practices that encourage collaboration and data sharing, this type of scenario that requires a lot of manual work is still common for many

caseworkers. Here is a deeper break down of three specific tasks that are key to collaboration, yet tedious and error prone without the right tools. n Completing forms. Workers need clients and providers to complete and sign forms, such as releases of informa tion or referrals to establish services. With current system limitations, the process is clunky when anyone outside the agency is involved. Best-case scenario is everyone is present to sign or finalize the form together, which has become increasingly difficult as more work is completed virtually. When that is not an option, the worker sends a partially completed form to the provider or client for a signature and then uploads or scans into the system the version they get back, which creates multiple copies. n Sharing content. Whether it is a court report, case plan, or summary of a family team meeting, workers are often required to share items from the case file with clients and providers. They often download the items to email, but that is not always secure and workers may find themselves locating and resending content repeatedly. Even using a file-sharing service causes additional friction and duplicate copies of files. There is also the risk of losing docu ments on the receiving end based on the external organization’s systems. • Uploading content. Workers often request documents and informa tion from clients and providers for the case file—for example, a child’s individualized education plan or a client’s behavioral health report. Today, workers collect this paper work in person or request it to be texted, emailed, faxed, or mailed back to upload or scan into the system. Someone must make sure the document ends up in the right case file, is categorized correctly, and the assigned worker knows it exists. If this process takes too long, clients may have to provide the same docu mentation multiple times, which causes confusion and frustration. Painting the Bigger Picture Over the past couple of years, agencies have adapted time and again to meet clients’ needs while protecting

their workforce and maintaining com pliance. However, when these tools are not designed to support the way human services workers engage clients, it creates more problems to be solved. For example, many agencies have had to cobble together disjointed software and apps that do not integrate or communicate. Each holds different pieces of a client’s story, which makes it difficult for their support system to work together to make decisions or determine next steps. They also create barriers to inviting clients and providers to participate in the case planning process. They also can become expensive for agencies based on how the cost is structured (for example, paying per interaction or signature). All of this can inadvertently deepen the divide among everyone involved. Future Possibilities It is time to flip the script on client engagement and collaboration. A secure portal that empowers clients and providers to be active participants in case planning not only improves engagement, but also takes some of the onus off workers, which is espe cially helpful during high turnover and workforce shortages. See what happens when we re-envi sion these same three tasks through the lens of what is possible with people centered, purpose-built technology: n Completing forms. Rather than waiting days or weeks to collect a signature on a release of information, the same form can be shared through the secure digital platform and com pleted in minutes—no matter where the worker or client is. This allows workers to obtain critical information or begin services for their clients as soon as possible, and when they are most engaged, which sets them on a more immediate path to success. n Sharing content. Workers can easily share case plans, team meeting summaries, and other appropriate portions of a case file with their clients, which can be accessed from any device. The worker can see if the client has viewed the documentation in question, which helps them drive more productive conversations. This adds a layer of transparency and trust to the process.

Laura Haffield is the Director of Market Advocacy at Northwoods.

Lauren Hirka is the Product Marketing Manager at Northwoods.

8

Policy&Practice June 2022

away from their usual duties to find and organize the required case files, you could use the portal to give the auditor secure access to the specific case files they need without all the extra work. Collaboration and Client Engagement in Action Cabarrus County Department of Social Services (DSS) in North Carolina and Carver County Health and Human Services (HHS) in Minnesota are leveraging a new client and provider portal, Traverse® Connect, to facilitate better collabora tion and information exchange. “Cabarrus County DSS is always looking for innovative ways to col laborate with clients and community partners. Traverse Connect will equip our DSS social workers with a new way to more seamlessly communicate with those partners and the families we jointly serve,” said Todd Shanley, chief information officer for Cabarrus County, North Carolina. “Streamlining the process of getting families linked with community partners who provide services based on their needs is critical in this world. Traverse Connect is a way for that to happen.”

Workers use the portal to share specific content and forms with stakeholders outside the agency and request signatures or documents to be uploaded. Clients or providers can use any device to securely view or submit requested information to be automati cally added to the electronic case file. Rachel Rosckes, a social worker with Carver County HHS, uses the technology to streamline how she completes annual documentation. She prepares the neces sary documents and forms, sends them out to clients electronically to sign, and collects the finalized versions back—all through just one tool. “What used to take me two weeks withmailing information to a family took me 30minutes from start to finish,” Rachel said. An industry built on human connec tion can only reach its full potential when people are at the center of every system and process in place to support the important work being done. Prioritizing client engagement while reducing the time and effort required to exchange information is a critical step toward empowering every indi vidual or organization with a stake in the case to focus on planning and providing the right care for the people they serve.

n Uploading content. A client’s thera pist can easily and securely submit progress reports to the case file in a way that triggers an automated noti fication to the worker. This cuts out manual handoffs and the progress report is added to the case file in a few simple clicks. The worker can immediately use this information to inform their decisions or actions. Any one of these improvements is beneficial on its own, but they become even more powerful when you consider other difficult, often manual processes that could be impacted as a result. Here are a couple of examples: n Cross-county collaboration. This type of technology could break down barriers when workers need to col laborate with their counterparts in another county or tribe (something that happens often right now due to staffing shortages). It can also break down information-sharing silos between different programs within the same county. n Prepping for audits. Think about the amount of time, labor, and resources typically required for an agency to prep for an audit. Rather than pull multiple staff members

9

June 2022 Policy&Practice

he Netflix series Maid , based on a memoir by Stephanie Land, offers a powerful picture of what individuals face when they navigate the health and human services system in the United States. The series tells the story of 29-year-old Alex, who, while fleeing an abusive relationship and caring for her two-year-old daughter, must negotiate a labyrinth of government social care systems and processes. Take the episode where Alex needs to show proof of income to be approved for child care vouchers, for example. With no temporary child care available for her daughter, she cannot take the job she needs to qualify for help with child care. In a similar vein, she cannot get a housing voucher without a landlord to approve and accept it. 1 Government systems, however well meaning, can often saddle users with such cum bersome and frustrating burdens. What can we learn from Land’s experience to make health and human services agencies and their partners more responsive, seamless, and effective? By Tiffany Dovey Fishman, Kelly Mahoney, Kate Holman, John McInerney, and JooYeun Chang A More Responsive, Seamless, and Effective Health and Human Services System Elevating the Human Experience T

Use Human-Centered Design to Uncover Obstacles and Unmet Needs A growing number of health and human services agencies seek better solutions through human-centered design (HCD). HCD places people — their beliefs, values, feelings, and ambitions—at the center of the design and delivery of public programs. HCD flips traditional social services approaches: instead of defining operational goals and then fitting them to client needs, it starts with an effort to understand key stakeholders and identify the root causes of their problems. Once providers understand these unmet needs, they can use the resulting insights to improve service design and delivery. Health and human services agencies are beginning to incorpo rate HCD in many programs. For instance, the Medicaid program has used it to consider the factors that keep members from renewing their benefits, thus losing their health coverage. Labor departments have used HCD to understand the experience of persons applying for unemployment benefits, eliminating opportunities for error and thereby reducing the burden on caseworkers. Child support agencies have used it to better understand why some

parents struggle to meet their support obligations, and to find creative oppor tunities to help them. Kentucky used HCD to figure out why many eligible individuals fail to take advantage of the Supplemental Nutrition Assistance Program Employment and Training (SNAP E&T) program. Researchers spent four weeks interviewing 58 people, including SNAP recipients, agency employees, and partners. 2 Among other conclusions, those interviews revealed that many recipients have a hard time complying with the pro gram’s requirements; the jobs they secure may meet immediate needs but do not match their long-term interests or ambitions, and many recipients fear that a new job will disqualify them for benefits without fully covering their needs. Kentucky used this informa tion to develop a new communications campaign to help participants make better use of SNAP E&T and help staff and partners better address partici pants’ actual needs. 3 Use Technology to Address the “Time Tax” The many hours that individuals spend applying for social care programs and complying with their rules constitute what The Atlantic ’s Annie Lowrey has dubbed the “time

tax.” 4 In exchange for benefits, social programs may exact a heavy toll in the form of time, extensive paperwork, and vexation. Lowrey documents examples of a Colorado resident with a chronic medical condition who spent more than 100 hours on paperwork to correct a lapse in his health insurance and a New York City resident who lost a job and then spent six months trying to find out why she had not received unemployment benefits, to illustrate the time tax beneficiaries can incur. 5 The Montana Department of Public Health and Human Services (DPHHS) has used advanced technology to ease the burden of the time tax for residents who need critical services, including access to food, health care, and cash assistance. When the COVID-19 crisis triggered a significant increase in online applications and service requests, DPHHS needed a solution to support its overburdened workers while maintaining high-quality customer service. In response, DPHHS started to deploy and then scale entities called Intelligent Digital Workers (or bots) to provide 24x7 customer service and enable case workers to focus on clients. The Digital Workers include: n Sophie, an online virtual assistant on DPHHS’ public website that provides 24x7 services such as prescreening

Kelly Mahoney is a Senior Manager leading the Health and Human Services and Labor Nerve Center in Deloitte’s Human Services Transformation prac tice. JooYeun Chang is a Senior Manager in Deloitte Consulting LLP’s Government and Public Services practice.

Kate Holman is a Senior Manager in Deloitte’s Government and Public Services Advertising, Marketing, and Commerce practice.

Tiffany Dovey Fishman is a Senior Manager with

Deloitte’s Center for Government Insights.

John McInerney is a Specialist Leader in the Government and Public Service (GPS) practice.

12

Policy&Practice June 2022

who could benefit from a range of social services. Founded in 2013, LavaMaeX started by providing mobile showers and toilets to help unhoused individuals in San Francisco. It soon expanded geo graphically and added more services, creating Pop-Up Care Villages (PUCVs) where people in need can access a wide array of services. 8 A PUCV resembles a food truck festival, with representatives from public agencies and private aid organi zations offering services from retired transit buses and commercial trailers. While enjoying live music, an indi vidual might receive, for example, food, a shower, and a haircut, plus information on employment and housing opportunities. People who engage with PUCVs say that the com passion and support available there have transformed their lives, boosting their self-esteem, and making them feel that they are once again part of the community. LavaMaeX has served more than 10,000 unhoused Californians, in collaboration with 185 partners and nearly 1,700 volunteers. 9 Looking Ahead Whether they offer what LavaMaeX calls “radical hospitality” or simply make it easier for individuals to access services that meet their needs, it is crucial for governments to interact with the people they serve in mean ingful and responsive ways. By understanding their clients, leading with empathy, and designing human centered experiences that meet individual needs, agencies can elevate the human experience. About Deloitte Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee (“DTTL”), its network of member firms, and their related entities. DTTL and each of its member firms are legally separate and independent entities. DTTL (also referred to as “Deloitte Global”) does not provide services to clients. In the United States, Deloitte refers to one or more of the US member firms of DTTL, their related entities that operate using the “Deloitte” name in the United States and their respective affiliates. Certain services may not be available to attest clients under the rules and

for benefits, general FAQs, and direc tions to nearest offices, as well as personalized services like current case/application status, reordering Electronic Benefits Transfer cards, and more. n REMI, which automatically “reads” returned mail when notices to the clients are returned for an incorrect or bad address. It then emails or texts the client to obtain an updated address, informs workers of the loss of contact, and notes any additional action required. n NOMI, which automatically under stands when customers fail to appear for their scheduled interviews with workers and sends Notices of Missed Interviews (NOMI). Using artificial intelligence (AI) technologies such as robotic process automation (RPA), intelligent optical character recognition (IOCR), and conversational AI, these solutions are hosted on a cross-cloud soft ware-as-a-service (SaaS) platform. 6 By leveraging this innovative AI strategy, the Montana DPHHS has been helping 150,000 customers per year, including 90,000 who received same-day service. DPHHS estimates that this solution will allow it to reallocate 30,800 hours of labor per year, yielding reduced workload and improved consumer convenience. 7 Focus on the Human Experience Social care agencies often view their clients through a program-centric lens, an inevitable byproduct of the way in which various programs have been established and run separately rather than as integrated parts of the health and human services system. Yet this approach fails to acknowledge the complexity of actual human beings, who may have multiple needs that cut across artificial program boundaries.

regulations of public accounting. Please see www.deloitte.com/about to learn more about our global network of member firms. This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte shall not be responsible for any loss sustained by any person who relies on this publication. Reference Notes 1. Horton, A. (2021, November 2). Netflix drama shines light on poverty. Crisis Assistance Ministry. https://www .crisisassistance.org/2021/11/02/ netflix-drama-shines-light-on-poverty/ 2. Sills, D., Hjartarson, J., Osmon, R. K., Fishman, T., & Datar, A. (2021, September 8). Transforming social care: Moving beyond “better, faster, cheaper,” Deloitte Insights, https://www2.deloitte.com/xe/ en/insights/industry/public-sector/future of-social-care.html 3. Ibid. 4. Lowrey, A. The time tax. (2021, July 27). The Atlantic. https://www.theatlantic .com/politics/archive/2021/07/ how-government-learned-waste-your time-tax/619568/ 5. Ibid. 6. https://www2.deloitte.com/us/en/pages/ public-sector/solutions/government digital-transformation.html 7. Ibid. 8. Frederick, D. (2022, February 21). How LavaMaeX restores dignity, rekindles optimism, and fuels a sense of opportunity for the unhoused. The Business of Giving. https://www.denver-frederick .com/2022/02/21/%ef%bb%bfhow- %ef%bb%bflavamaex-restores-dignity rekindles-optimism-and-fuels-a-sense-of opportunity-for-the-unhoused/ 9. Hjartarson, J., Kusmu, P., & Gadwa, B. (2022, February 23). Reweaving the social safety net: Building modern, responsive social protections. Deloitte Insights. https://www2.deloitte.com/us/ en/insights/industry/public-sector/social safety-net-for-social-care-system.html?id= us:2sm:3li:4diUS165061:5awa:6di:MMDD YY::author:alumni&pkid=1008519 Copyright © 2022 Deloitte Development LLC. All rights reserved.

A California-based nonprofit called LavaMaeX serves as an example of how to integrate care

practices while elevating the human experience. The all-in-one model for its health and well-being pop-up facilities can connect with people quickly and conveniently, creating a welcoming and conducive environment for those

13

June 2022 Policy&Practice

14

Policy&Practice June 2022

Driving Better Outcomes Person-Centered, Equity-Focused, and Data-Driven Systems

By Karen Snyder, Maryam Ghariban, and Leah Dienger

H

ealth and human services delivery systems provide critical support for children, families, and individuals. Intended to support people through

life’s inevitable ups and down and toward stable, long-term wellness, ideally, this means that the system works with and for people— not the other way around. IBM has been working with states, counties, and tribes who desire to strengthen their programs and support system. These clients want to create service delivery that is more person centered, equity focused, and data driven. Below are three case studies where solution designs leverage a stakeholder and community engagement approach that is truly human centered and is ultimately driving better outcomes.

15

June 2022 Policy&Practice

Case Study #1: Monroe County Systems Integration Project (SIP) The Challenge “Program rich but results poor.” This was the finding from the IBM Smarter Cities Challenge study in Rochester, NY in 2015. The study identified several strategies to improve com munity health and reduce poverty. It realized the potential of communities and neighborhoods to stop poverty before it starts. Strategies include leveraging data for greater insight, coordinating services to optimize outcomes, and introducing preventive strategies.

The Results Creating a Future Shaped by Communities and Neighborhoods n People in the community remain at the center of this project. Individuals and organizations are working collaboratively to build an interconnected system focusing on addressing care in a personal ized way. Making Better Decisions by Using Community Data n A secure data hub helps to share information and coordinate care. Coordinating Services for Better Outcomes n Improving access to needed services by creating connections for indi viduals and families to programs and services based on their needs. This includes housing, food, health, employment, education, and more. Introducing Preventive Strategies to Stop Poverty Before It Starts n Improving coordinated cross-sector interventions by working with multiple organizations. Collectively helping to transition individuals and families from crisis, to stable, to thriving. Case Study #2: DelawareTribe of Indians The Challenge The Delaware Tribe of Indians operated a paper-based system for services and benefits. In 2021, the tribe undertook a digital transforma tion project to improve support for their clients. The project enabled digital case tracking of Child Welfare, Child Support, Domestic Violence, Grant Management, and Client Court Cases. for their clients was to modernize the tribe’s applications to improve service delivery. A digital profile was created for each individual receiving benefits and/or services. As clients seek benefits and services, caseworkers are now able to view their client’s digital profile, assess the current situation and status, The Solution The first step to improve support

The Solution The Systems Integration Project (SIP) began to explore these recom mendations in 2017. From the start until the present day, the SIP works across a diverse network of committed community providers and community members. The SIP seeks to keep people at the center of an interconnected system of education, health, and human services with a solution called MyWayfinder. IBM reflects SIP’s principles and approach by collaborating with diverse community stakeholders in the design and development of MyWayfinder. With agile processes, SIP and IBM can rapidly implement community feedback and build a solution to incorporate the com munity’s needs and desires. Today, SIP provides easy and acces sible digital tools and neighborhood navigation centers. Individuals can locate support and service pro viders can manage their workflows. MyWayfinder empowers members of the community to better understand their needs and make personal con nections with local service providers who can help. Individuals and families maintain control over their personal information. They decide who can access their 360-view Dashboard. Service Providers can maintain con nection with community members who have added them to their Care Team. The 360-view Dashboard allows providers to holistically view an individual. They can reduce service duplication and address services gaps. 211 Community Connectors also leverage MyWayfinder to locate and share resources with individuals calling into 211. Platform Administrators can update content on MyWayfinder. The inte grated Content Management System manages accounts across the platform. To design better experiences and identify friction, administrators can review the Web Analytics Dashboard where they can run reports to analyze de-identified data. Data and reporting metrics displayed in dashboards also provide administrators the opportu nity to identify “resource deserts.” These are communities where specific services are needed but are too limited or nonexistent.

Karen Snyder is the Lead Health and Human Services Industry Partner on the Public Market team at IBM Consulting.

Maryam Ghariban , MPH, is a Senior Managing Consultant on the Health and Human Services Public Market team at IBM Consulting.

Leah Dienger , MSW, is a Senior Consultant on the Health and Human Services Public Market Team at IBM Consulting.

16

Policy&Practice June 2022

associated with COVID. There was a strong desire to identify opportuni ties for children and staff to remain in school. Leveraging the data collected from the contact tracing efforts, Rhode Island identified schools as the safest place for children and with a lower transmission rate due to school-imple mented policies. The Result With this knowledge, a Test to Stay program was implemented, where exposed staff and children were per mitted to attend school in adherence to a set of policy guidance. This ini tiative increased school attendance, which resulted in a decrease of educa tional gaps, and reduced the financial burden on families who were previ ously required to stay at home with their children. NOTE: During the pilot Test to Stay program, which included one school district over a month period, roughly 402 school days were saved that would have otherwise been COVID-related absentees. The program was extended across the state. It created an equitable opportunity for children to remain in school and reduced educational gaps. Families, who were disproportionately impacted by the pandemic, could remain at work, thus reducing undue financial burdens. Conclusion Shining a light on existing systems has exposed the gaps into which individuals and families in need of support can easily fall more deeply, and at greater cost, into crisis. With technology capabilities growing at exponential rates, public-sector agencies are discovering an incredible opportunity to improve individual and family health and wellness outcomes. They are increasing access, improving efficiency, and delivering a quality experience while reducing costs. Essential to the development of any system design aimed to achieve these outcomes, however, are the voices of diverse stakeholders and community members. In our experience with health and human services clients, this is the key to achieving person-cen tered, equity-focused, and data-driven systems of care.

COVID operations team with COO Kristine Campagna, and Education Setting Lead Tara Cooper, partnered with IBM policy analysts to design an engaging public health strategy addressing the needs of the community and key stakeholders. The Solution Shift fromMandates to Community-Gathered Input The State of Rhode Island priori tized schools at the beginning of the pandemic. It focused on reopening schools while maintaining high public safety measures. The mission meant moving an entire system—not through traditional mandates—but through a community-driven strategy. IBM developed programmatic solu tions to gather surveillance data from schools en masse. Using COVID-19 case information collection via phone investigations and targeted online surveys, RIDOH and IBM were able to use their system to automati cally detect outbreaks and potential clusters across the state. This allowed Rhode Island to respond to outbreaks faster. It reduced transmission within schools and mitigated educational gaps resulting from COVID-related absenteeism. Voice of the Community Built Focused Playbooks Community enablement promoted quick results within educational facilities. The Rhode Island strategy of enablement started with the commu nity voice—both parent and youth—to understand local community needs and provide accurate updates to policy and clinical guidance. Each week, school districts, gathered with RIDOH, were prepared with data-driven insights to combat the next step of the disease spread and understand the needs of the communities. The state developed playbooks for the commu nity to efficiently report, understand, and prevent disease spread. Investigate Community Needs and Create Data-Driven Policies With the progression of the pandemic, there was growing frus tration among families and children regarding the impacts of absenteeism

and more efficiently support their client through: n Acquisition and review of the intake/report n Determination of appropriate service (case) type determinations such as Child Welfare, Child Support, or Domestic Violence n Creation of service-specific activities n Scheduling of appropriate follow-ups The Results As a result of the tribe’s initiative to better support individuals, a holistic, person-centered approach to care has been achieved. By improving access and creating efficient delivery of necessary benefits and services, tribe members can improve their clients’ well-being more readily. An agent of the tribe can now pull specific client information in seconds. Before, it was a lengthier, manual process of opening a file cabinet to find the client’s folder and sift through its contents. Today, agents can leave notes, send emails, see the account balance, and child and family services statuses more rapidly. They can also see court case dates related to client cases. The agency and workers are able to efficiently stay up to date on their client activities and easily view the various benefits and services being provided. A secure application provides access with specific roles and authority. This permits only agents with authorized credentials to see sensitive client information. Case Study #3: Rhode Island Department of Health: COVID-19 School Openings The Challenge The COVID-19 pandemic shattered a fragile education system. Educational facilities faced understaffed programs and under-resourced health programs. A requirement to understand each educational community and drive deci sions based on data became critical to the handling of the disease outbreak. Community members in Rhode Island were quick to respond. They were eager to understand the educational facilities’ stance on national policy and clinical guidance. The Rhode Island Department of Health’s (RIDOH)

17

June 2022 Policy&Practice

18

Policy&Practice June 2022

How Aligning Small Conflicts in Application Requirements Makes Benefits Easier to Access By Angela Colter and Kelli Ho HEALING POLICY PAPERCUTS

I

ntegrating eligibility and enrollment benefits is an increasingly important 1 undertaking for state govern ments around the country. People who qualify for multiple public benefit programs should not have to fill out multiple applications that require the same basic informa tion to access these benefits. But states already in the process of integrating benefits 2 are encountering an issue—differing, and at times contradictory, submission requirements dictated by the federal agencies running these programs. Let us take the hypothetical example of a state that wants to combine applications for health care and nutrition assistance programs. Ideally, an applicant would only need to complete one application that could be used by caseworkers to deter mine this applicant’s eligibility for both programs. But when the state’s digital team sits down to work on integration, they realize that one program only requires name, address, and signature in order to apply, while the other program requires additional information. Because these programs have different information needs written into their policies, inte grating these applications suddenly becomes much thornier.

19

June 2022 Policy&Practice

Nutrition Service (FNS) funds SNAP; any state looking to offer applicants a single integrated application must account for both CMS and FNS appli cation requirements. Often, these requirements are open to interpretation by the person charged with reviewing this work, such as a regional FNS officer. This can lead to even more con fusion or inaccuracies when it comes to complying with federal requirements. “The requirements for FNS and CMS were the drivers of the detailed requirements that the benefit applica tion question flows had to meet,” said Recic, adding the example of differing requirements for whether an appli cation must show privacy notices or disclaimers. “Many times, the require ments of each entity were in conflict, which presented a unique situation that had to be navigated.” This, and other related issues that impact how states interpret and imple ment federal agency requirements, were outlined in a recent report 8 by the Beeck Center. “There are much-needed ongoing efforts to use human-centered design for improving single and multi-benefit applications and eligi bility screening,” the report states. “However, the inherent complexity remains even as the service delivery improves, since the rules that govern the benefits are complex.” What We Encountered Integrating Benefits in Nebraska and Vermont In our work integrating benefits in Nebraska and Vermont, we mapped the requirements from both FNS, which runs SNAP and WIC, and CMS, which runs Medicaid, Medicare, and Healthcare.gov, in order to build enrollment tools that accommodate both. That is when FNS and CMS’s differing application requirements became an obstacle. For example, both FNS and CMS share a requirement that the only information necessary to apply for certain benefits are name, address, and contact information—some times called a “minimal submit” or "quick submit" requirement. But if an applicant submits more information in their application, FNS will accept whatever else they fill in. Then CMS

require unique information, forcing applicants to pause to hunt down their net monthly household income for one application and gross monthly income for another. It could also mean keeping track of login information for multiple online accounts if they need to stop and complete the application later. These differing requirements might seem at first like small burdens. In reality, they are policy papercuts that, when added up, create a much bigger pain point for many applicants. For populations that are often the most strapped for time and resources, these obstacles are even more acute. It is what makes these policy papercuts more than an issue of inconvenience—it is about ensuring equity in access to benefits. In an ideal integrated experience, an applicant could log in to one location and apply for multiple benefits, such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP), using a single application. This makes it easier for applicants to access benefits by reducing the need to submit multiple applications. It can also improve the accuracy of submitted information. As Dee Dee Recic, a product manager in Nebraska, one of our state partners, said, “[An integrated application] eliminates the need to enter the same information multiple times for each program…ensures that unnecessary questions are not asked, and provides the ability to edit information once for all programs—all of which significantly decreases the amount of time to apply for all benefits and improves the quality Minnesota, Louisiana, and more, 7 have been working on and launching integrated benefits projects. With the availability of significant funding to modernize benefits programs from the American Rescue Plan, even more states could follow. But state-adminis tered benefits are typically funded and regulated through federal agencies. That means that states looking to inte grate benefits must navigate differing, and at times contradictory, funding and compliance requirements decided at the federal level. For example, the Centers for Medicare & Medicaid Services (CMS) funds Medicaid while the Food and of the information provided.” States, including Michigan,

At Nava, where we partner with government agencies to build digital services that are simple, effective, and accessible, we have encountered this issue firsthand. We helped the states of Nebraska 3 and Vermont 4 in their ongoing effort to integrate public benefit programs. But in the process of working with these states, we saw how something as small as a single form requirement on an application has unforeseen impacts downstream. This patchwork of compliance requirements across federal agencies creates a burdensome experience for applicants trying to access benefits. This makes it harder to integrate benefits, a worthy undertaking that falls in line with the President’s latest executive orders on improving customer experience 5 and improving equity 6 when it comes to government programs. Aligning these fragmented requirements is one step toward building a truly human-centered process for state benefits programs. How Conflicting Requirements Burden Applicants The process of applying for multiple public benefits can be a cumbersome experience. Applicants might need to fill out the same information over and over again, or need to fill out forms that

Angela Colter is a Program Director at Nava public benefit corporation.

Kelli Ho is a Senior Designer/ Researcher at Nava public benefit corporation.

Policy&Practice June 2022 20