412794-Early-Lessons-from-the-Work-Support-Strategies-Initiative-Rhode-Island.PDF

Early Lessons from the Work Support Strategies Initiative: Rhode Island Heather Hahn and David Kassabian March 2013 Acknowledgments The Ford Foundation has provided generous lead funding for the Work Support Strategies (WSS) project, committing more than $20 million in total The Special Fund for Poverty Alleviation of the Open Society Foundations, the Kresge Foundation, and the Annie E Casey Foundation also gave crucial support The authors would like to thank Olivia Golden, Stacy Dean, Dottie Rosenbaum, Gina Adams, and Rhode Island’s WSS team for their review of earlier drafts and for the many comments and insights provided The authors would also like to express gratitude to the many staff in Rhode Island who participated in the site visit interviews; to Serena Lei, Fiona Blackshaw, and Scott Forrey of the Urban Institute’s communications team for their extraordinary editorial assistance; and to members of the national WSS team, including Lindsay Giesen and Michael Tutu, for their assistance The views expressed in this publication are those of the authors and not necessarily reflect those of the Urban Institute, its trustees, or its funders Contents Rhode Island’s Goals for the Planning Year State Background Using Personal Outreach to Bring Everyone on Board Understanding the “As Is” to Get to the “To Be” Striving To Build Structure and Forward Movement 12 Forging Common Goals among the Health Insurance Exchange, Medicaid Expansion, and Human Services 14 Engaging Frontline Workers in a Unionized Context 16 Using the Planning Year to Move Past Historical Barriers 18 Conclusions 20 References 22 Methodological Note 23 Although Rhode Island offers generous public benefits, Work Support Strategies participation among eligible residents in certain programs is low compared with other states The inefficient process of enrolling for work supports has become frustrating for clients and staff A lawsuit by advocacy groups over the timeliness of food assistance benefits added additional stress to the system, which was further tested by the growth in caseloads due to the recession Although a previous effort at reform had been unsuccessful, the state decided to try again with outside help In 2011, Rhode Island was awarded a Work Support Strategies (WSS) grant to streamline the system for connecting low-income families to work support benefits Supported by private philanthropy, this multiyear initiative gave grants to select states to test and implement more effective and integrated approaches to delivering key work supports, including health coverage, nutrition benefits, and child care subsidies Simplifying and modernizing these processes can help improve the health and well-being of lowincome families, save states money, and improve overall efficiency Rhode Island’s Goals for the Planning Year In its action plan for the WSS project, the state described its work support programs and processes as “siloed, fragmented, redundant, inefficient, and costly Frustrated clients and hardworking but stressed staff are overburdened by multiple and confusing program applications, bureaucratic business processes, and inflexible technology Work Support Strategies (WSS) is a multiyear initiative to simplify the process of getting work support benefits Working directly with selected states, WSS seeks to improve the health and well-being of low-income families by increasing enrollment in work support programs; deliver benefits more effectively and efficiently, reducing administrative burdens on states as well as clients; and evaluate the impact of these streamlined approaches, disseminate lessons learned, and inform state and federal policies WSS focuses on three work support programs: the Supplemental Nutrition Assistance Program (SNAP), Medicaid and the Children’s Health Insurance Program (CHIP), and child care subsidies through the Child Care and Development Block Grant Participating states may choose to add other programs, and most have done so In fall 2010, WSS invited states to apply for one-year planning grants, with the opportunity to continue to a three-year implementation phase Twenty-seven states submitted applications, and nine were competitively selected: Colorado, Idaho, Illinois, Kentucky, New Mexico, North Carolina, Oregon, Rhode Island, and South Carolina During the planning phase, the selected states received $250,000, expert technical assistance, and peer support from other states With these resources, the grantees performed intensive diagnostic self-assessments, explored business process strategies, established leadership structures, and developed data-driven action plans that address policy and practice changes This report is one of 10 (one on each state, plus a cross-cutting report) describing state activities during the planning year Early Lessons From The Work Support Strategies Initiative: Rhode Island and polices.” Rhode Island’s proposed goals for the planning year centered on improving client access to benefits, increasing cross-program integration, and making service delivery more efficient Key motivations for Rhode Island’s involvement in the project were a series of ongoing problems that it hoped WSS could solve Along with a low participation rate in some public benefits, the state struggled with low morale and high overtime among its employees after a major reduction in staffing Due to changes in retirement benefits, a large number of workers in the department decided to retire within a very short timeframe, which resulted in a deep loss of institutional knowledge and Work Support Programs Included in Rhode Island’s Planning Year SNAP: Supplemental Nutrition Assistance Program RIte Care: Rhode Island’s name for family Medicaid CHIP: Children’s Health Insurance Program Child Care Assistance Program RI Works: Rhode Island’s name for Temporary Assistance for Needy Families (TANF) experience, according to several senior WSS project team members Rhode Island also needed better coordination among siloed programs Often, applicants must see one worker for SNAP or TANF and another for Medicaid, repeating similar information and paperwork for both programs In addition, a July 2009 lawsuit contesting the timeliness of SNAP application processing led to the state’s promising the federal court to send monthly statistical reports to two client-focused advocacy organizations State Background Before the official kickoff of the WSS project, two tiers of Rhode Island’s executive government leadership were in a period of transition First, newly elected Independent Governor Lincoln Chafee replaced outgoing Republican Governor Donald Carcieri in January 2011 That same month, Chafee nominated Sandra Powell, previously state labor director, to serve as director of the Department of Human Services (DHS), replacing former director Gary Alexander Rhode Island had previously tried to streamline key work support benefits through the Modernization Initiative project Started in 2009 by Alexander, who served a dual role as Work Support Strategies A Quick Glance at Rhode Island Population (in thousands): 1,052 Share of population living below 200% of the federal poverty level (FPL) (in 2011):a 30.8% b Unemployment rate (September 2012): : 10.5% Share of eligible residents participating in SNAP (in 2010):c all individuals, 81%; working poor, 63% d Share of eligible children participating in Medicaid (in 2010): 87.9% State Medicaid upper income eligibility limit as % of FPL: e children, 250%; working parents, 181% Programs state or county administered? State Number of local DHS offices: Lead WSS agency: Department of Human Services (DHS) SNAP governance: DHS > SNAP Medicaid governance: Executive Office of Health and Human Services (EOHHS)/Department of Health > RIte Care Child care governance: DHS > Child Care Assistance Program Sources: a U.S Census Bureau (2011 estimates); b Bureau of Labor Statistics (2012); c U.S Department of Agriculture (2012); d Kenney et al (2012); e Kaiser Family Foundation (2013) secretary of the Executive Office of Health and Human Services (EOHHS) and director of DHS, the initiative aimed to improve access to benefits and services within the health and human services agencies, including but not limited to DHS The project also sought to improve the overall quality of the delivery system, including business process redesign and IT improvements Staff made inroads developing a work plan, convening an advisory group, and beginning research on improvements, but the effort lacked direction and was overreaching in its scope, according to senior DHS managers Some external partners also expressed concerns about the previous initiative, believing that it had focused on the needs of the agency and not of families The remainder of this report is organized into six key areas that were critical aspects of Rhode Island’s planning year: using personal outreach to bring everyone on board; understanding how the process really works for clients and for staff in field offices; building structure and momentum for the project; bridging the divide between health care reform and human services delivery reforms; engaging frontline workers in a unionized context; and using the planning year to move past historical barriers Early Lessons From The Work Support Strategies Initiative: Rhode Island Using Personal Outreach to Bring Everyone on Board “I have to go back to Director Powell She was invested from day one, including the way she works with other people I think everyone felt valued and everyone felt heard and that their contributions mattered That makes you want to get to work.” —WSS program manager Senior-level Rhode Island WSS staff identified a number of planning-year successes in building consensus on the project’s mission and scope, if not its specific plan They reported that the project benefited from strong vision and leadership at senior and middle levels, engaged stakeholders, relied on advisory groups, and involved field-level DHS staff in the policy process in a novel way They felt that this approach to getting everyone on board, especially local program staff, is a marked contrast to Rhode Island’s previous efforts to improve efficiency and stands as a model for the state as it prepares for the project’s next phase DHS director Sandra Powell was a driving force in getting project buy-in and building momentum, signaling to staff that the department was behind WSS, those under her repeatedly said Powell already had experience reforming large systems in her previous post as director of the state’s Department of Labor and Training, and this understanding eased her transition and translated to WSS, said a member of the Rhode Island team Powell was not with the department or the WSS team when Rhode Island drafted its proposal; however, her backing of WSS and her approach to inclusion were clear from the beginning Early on, Powell designated an associate director as the WSS lead, which was a sign of the value she placed in WSS, some senior team members said Both the WSS lead and the project manager actively engaged internal and external stakeholders by leading weekly or biweekly meetings and advisory groups Powell sought the input of those outside DHS and at different rungs within the agency, which may have been a different approach than that taken in the past, according to an analyst with one of the state’s community partners Also key was the director’s regular communication and WSS status updates with more senior political officials, including the governor and the secretary of the Executive Office of the Department of Health and Human Services DHS also actively engaged the state legislature, whose support was critical to the state’s ability to make progress, WSS team Work Support Strategies members said The legislature backed the WSS initiative by committing to assist the initiative and provide for changes Some members also participated in planning and advisory committees The connections WSS forged with external groups was built on an existing network of relationships DHS had already forged The department had a history of soliciting the perspective of outside groups Two of the three chairs of the previous Modernization Initiative came from advocacy organizations In addition, some community partners already were serving on programspecific advisory committees established by DHS Community advocates and senior staffers within DHS separately praised the collaborative and trusting relationship they shared, which served as a foundation for ensuring advocate support and, ultimately, the momentum to carry out WSS In addition, DHS leadership convened a WSS advisory committee of outside stakeholders, which met four times over the course of the planning year These and other partners joined workgroups that the department formed as its main vehicles for proposing and managing its WSS activities Two groups, Rhode Island Kids Count and The Economic Progress Institute, entered into formal relationships with DHS to serve on the WSS advisory committee and workgroups The department also benefited from informal relationships with outside groups An outside advocate was the first to notify the state of the grant opportunity, and outside money was used to hire a grant writer Although advocates had worked with DHS in the past, some said they saw an important change in the overall tone from the state with the new governor and Director Powell Though expressing a different perspective than that of DHS in their assessment, several advocates perceived the previous governor’s language and policy choices as emphasizing reduced, rather than expanded, access to safety net programs Some advocates thought clients had sometimes been treated as “guilty until proven innocent” in applying for benefits and felt the department put the burden on applicants to navigate barriers to enrollment and used administrative processes to divert applications Some advocates also thought that DHS’s efforts at outreach suffered historically from poor communication and a “real disconnect” between the department and community, with DHS notices that were “incomprehensible” to clients Internally, senior project staff engaged a broader range of agency participants than in previous initiatives DHS middle management, including regional managers, were included as key participants The regional managers traveled with senior team members to conferences with all the Early Lessons From The Work Support Strategies Initiative: Rhode Island WSS grantee states and to some site visits focused on technical assistance Within the regional offices, most middle managers adopted the WSS goals and were instrumental in moving the project along Senior WSS team members thought it was crucial to have middle managers on board, as they had observed in prior initiatives that middle managers can be perceived as obstacles by frontline staff if they are not fully engaged “We need to make sure we have enough support [and] spend enough time wrapped around our field offices as we implement these changes,” a WSS team member said Three subgroups—business process mapping, data analysis, and policy—met at least once a month, actively engaging internal and external stakeholders “The structure—having regular meetings, following up, and seeing a result in the end—is the piece that’s new in this planning year and is something that hasn’t happened before,” a WSS senior team member said Through the subgroups, team members discussed problems, proposed policy changes, and helped identify components to be included in Rhode Island’s action plan The subgroups helped maintain focus and work toward consensus When the teams weren’t meeting, members were assigned specific tasks to be followed up on by the next meeting While this broad approach to including outside groups and several layers of internal staff was seen as an important success, it raised challenges as well, particularly given the history the department had to overcome For one thing, not all participants felt equally heard One advocate reported feeling like the advisory group meetings were simply DHS updates and did not provide an opportunity for two-way feedback Another challenge, reported both by external and internal participants, was that the large group settings could be hard to move to action An external participant reported the group meetings always went over on time and the discussion never really came to a resolution or consensus An internal participant wondered if the larger group meetings were less effective than smaller meetings And, as explored more fully below, state staffers were already stretched in many directions, so it was difficult to fully staff the advisory groups As a result, several advocates reported feeling frustrated with the quality and timeliness of information on policy and business processes Addressing two challenges—state staff gaining sufficient resources to move an agenda forward and ensuring that staff document and analyze the on-the-ground process—were core activities of Rhode Island’s planning period Both are described below Work Support Strategies office regional manager solicited volunteers for the PDSAs to avoid imposing on workers who were uncomfortable with the change.) The workers began by conceptualizing and analyzing business processes through hands-on exercises By the end, they were “fish-boning” or sketching problems that involve everyday workload and processes Given a flow chart mapping how many steps a client goes through to get one application, the workers sought to create an improved model without roadblocks and inefficiencies The workers who participated spoke glowingly of the exercise “We didn’t realize all the problems everybody had,” one worker said A fully refined idea was then tested as a pilot and adjusted as necessary If successful, the change would be rolled out program-wide Workers from the Providence office conducted two formal PDSAs with the help of the Southern Institute and a number of smaller, improvised initiatives on their own, without technical assistance A PDSA to serve SNAP applicants the same day they applied was the most successful It was tested as a pilot in mid-October 2012 before being released statewide later that year Other related activities included a lobby redesign for one local office to better accommodate the same-day service model and a switch from individual caseloads to a team-based model for child care subsidies A medical assistance line manager in the Providence office crafted an “unofficial” PDSA to change case assignment from an alphabetical to a chronological system A senior member of the DHS administration concluded that operational change—and, at its heart, cultural change—was more challenging than streamlining processes or aligning policy “We lacked the resources to focus on this issue before,” another senior staffer mentioned “Now we know the issues, have better communication, better notices to clients, more welcome surroundings, and understand the language barriers a little more.” The WSS team’s third task to better understand the “as is” was to examine data, though they came up against major obstacles along the way One obstacle, according to core WSS and DHS staff, is the state’s legacy eligibility system, InRhodes, which was implemented in the late 1980s “I think our biggest challenge in the project is that the technology we’re using is so old,” a WSS Early Lessons From The Work Support Strategies Initiative: Rhode Island Plan-Do-Study-Act in Providence Providence used the Plan-Do-Study-Act (PDSA) strategy to test and implement same-day service to SNAP applicants With the traditional process, applicants came in to the office to fill out paperwork and schedule a time to return for an interview before receiving benefits In the pilot, at least one SNAP worker was dedicated to processing SNAP cases right away so that applicants could enroll and leave with an EBT card in their first visit “The first client…was like, ‘This is amazing,’” a SNAP line manager from Providence said “People tell clients you have to wait weeks for benefits and he walked out the same day with an EBT card.” Partway through the day, SNAP workers doing same-day processing switched back to traditional applications DHS officials reported that the pilot definitively showed that application processing had been improved With same-day service, the number of pending cases dropped by about half and workers reported better control over applications and pending applications “We… noticed a huge decline in foot traffic in offices,” a DHS regional office manager said Under the “old system …we may see you four times, now it’s once.” A second PDSA aimed to reduce the number of incomplete applications coming in to DHS offices from family resource centers At these centers, which are located in hospitals or other medical facilities, family medical eligibility technicians help families complete benefit applications Technicians were urged to forward the applications to DHS offices within two to three days, but the applications were often incomplete Under the revised process, technicians were instructed to hold on to applications for five to six days, giving applicants more time to bring in missing documentation The revised process saved DHS workers the burden of handling incomplete applications and reduced the burden on applicants of bringing missing documentation to the DHS office rather than back to the family resource center This effort was begun as a pilot but was suspended due to disagreements involving worker job function and contractual agreements team member said “It’s not quite as flexible as it needs to be and not quite as easy to get data as you might like.” Many system reports must still be distributed in paper form, even though the department is trying to switch to an electronic system The old system also has no mechanism to share recipient data between programs and therefore cannot make cross-program data available (for example, data to evaluate if clients as a whole were encountering common barriers to maintaining access) Officials said that, despite these challenges, InRhodes possesses positive aspects that ought to be recognized in a plan for a new platform, but their immediate challenge was to find and use data to diagnose problems and design solutions The WSS team found that Rhode Island had organizational and practical difficulties using what data it had As one senior DHS official said: “We realized we had data but couldn’t get to it We then realized there’s a new data warehouse, but the warehouse wasn’t able to answer the questions that we presented.” The problem boiled down to having lots of data but no efficient and timely methods for pulling them together Early efforts to pull the data together proved costly and time-consuming 10 Work Support Strategies Rhode Island contracts with a vendor for its data warehouse The department must go through the vendor to compile and present data, adding layers of permission to get through to run queries The legacy eligibility system coupled with the state’s reliance on a vendor for access to data made it difficult to get comparable reports over time, a senior DHS official explained Also, the silos among programs extended to the data warehouse: even though the warehouse contained data fields across programs, fields for one program will not automatically show up for another program and must be manually requested Despite these obstacles, the WSS team successfully gathered data to understand several key aspects of the process that had never before been analyzed Most dramatic was their analysis of churning in SNAP and child care Eligible participants were frequently dropping out of these programs and then reapplying a short time later, indicating that they had not properly renewed their benefits Churning causes families to lose needed benefits in the interim and can be a waste of time and money for states, as workers must reopen cases and reenroll clients SNAP churning had not been analyzed in the past because the state’s data system was not programmed for this analysis After performing a one-time analysis in the WSS planning year, senior managers including the DHS director found the results eye-opening “The data that was pulled, the churning, that was something I probably had never looked at, and that was something important to recognize and see,” one senior program manager said “It was very interesting.” The WSS team analyzed churning in the child care program because preliminary numbers raised concerns, according to a core member of Rhode Island’s team “The churning data confirmed we have the smallest program with the largest churn in it That’s a big glaring red flag.” The requirement that customers provide actual work schedules was contributing to churning, as these schedules often are difficult for clients to provide When clients did not turn in work schedules, “you ended up with unnecessary denials, which infuriated everyone and led to administrative hearings, which then took up…time,” a core member of Rhode Island’s team said Senior leaders said they also were enlightened by cross-program participation data and data on timeliness The cross-program data “was very helpful to us,” a senior program manager said “It allowed us to ask what’s missing Why are some recipients receiving one benefit but not another? Or why are staff doing such a thing to miss a certain population?” By more clearly Early Lessons From The Work Support Strategies Initiative: Rhode Island 11 understanding the source of the problem, the state could begin to think concretely about how to fix it The state’s study of timeliness data prompted a more careful look at barriers to providing service to recipients The team then discussed potential rule changes and modifications to office procedures and staff activities that could speed up service This analysis prompted the DHS administration to consider what was duplicative and unnecessarily burdensome to clients, thus causing delays in the system The question helped state staff gain a new perspective on verifications: adding more to ensure clients aren’t cheating the system adds unnecessarily to staff workloads, costs, and delays As a senior member of the WSS team said, “That was a big one that helped us strip away things to the basics We were over-verifying, and we used data to help support the removal of some program requirements.” Looking toward the future, DHS staffers see further improvements in the state’s capacity to gather and analyze data The health insurance exchange and new eligibility system are expected to help, as are planned future enhancements to the still-new data warehouse A data dashboard, a tool for compiling data electronically, was about 65 percent complete by the end of the state’s WSS planning year The dashboard will be more powerful and useful in generating data reports than the current ad hoc queries and it can be expanded after it is implemented to yield more data points Striving to Build Structure and Forward Movement “We did a little bit of a work plan, we had some presentations, we did a lot of research here and there, but it wasn’t directed to any one place.” —WSS team member describing the challenges of a pre-WSS initiative, the Modernization Initiative Past experience in Rhode Island suggested challenges in turning good ideas into actual, fully implemented change Staff reported that past efforts to streamline or improve access saw few policies make it out of the planning stage The Modernization Initiative, the most recent preWSS initiative along these lines, was criticized by some who had a formal role in its activities for 12 Work Support Strategies lacking direction and failing to accomplish its goals Staff reported that other earlier initiatives, such as a universal application for all programs, were never implemented During the WSS planning year, the Rhode Island team worked hard to change this pattern Sometimes, the choices that represented important project strengths also posed challenges, especially in a small, thinly staffed state For example, as noted earlier, Director Powell appointed a DHS associate director as project lead, signaling the importance she placed on the project But because the state was behind in hiring an outside project manager to support the lead as originally intended, the associate director also played that role for most of the year This arrangement ensured high-level attention but potentially risked bottlenecks given all the other important priorities senior staff had to attend to Staff in general reported that they tried to manage the project’s sometimes frenzied pace through clear structure and group accountability One WSS staffer said it was frustrating being unable to follow through on every area in need of change Because of the time crunch, policy areas that ideally would have been considered had to be narrowed in focus, staff reported, leaving some potential activities unexamined Team members also reported feeling nervous a few months after the project kickoff One core member of the WSS team said learning to accept feeling overwhelmed was the most difficult aspect of the project Despite this nervousness, the WSS team rose to the challenge and stayed on track toward the goal Overall, staff reported that WSS succeeded in several important ways dealing with project structure, in contrast to past initiatives They found that the administrative structure of the national WSS project, which included monthly technical assistance check-in calls and required assessments and data exercises, added focus and kept Rhode Island’s project team moving forward Monthly and quarterly check-ins broke the planning year up into more manageable pieces and kept the team on task as they worked to complete certain steps before the next checkin “I loved the monthly phone calls, I love the agenda, and I think it keeps people thinking,” a core WSS manager said WSS technical assistance offered help and outside perspective when needed Staff also found the site visits to other states to be useful Not only were state-level senior managers sent to site visits, but also the regional managers who oversee the service delivery offices “When we saw [that] the way New Mexico does business was similar to what Early Lessons From The Work Support Strategies Initiative: Rhode Island 13 we were talking about two years before…it takes the fear away,” one regional manager said “When you make changes, you’re afraid you’ll be a failure When you see what works, it makes it easier.” Finally, staff saw the project’s visibility as an assist to staying on track The planning-year grant award to Rhode Island, albeit a relatively modest amount, gave importance to the issue of simplifying access to work supports and helped reignite progress where the Modernization Initiative had stalled In the words of a sub-group participant: “When you have a high-profile grant opportunity, it brings a level of seriousness to the effort We were excited to create movement on something when we were spinning our wheels before.” Forging Common Goals among the Health Insurance Exchange, Medicaid Expansion, and Human Services “The biggest barriers right now are [silos] It’s not just DHS but the whole state…Your biggest barrier is going to be asking, ‘How I bring it all together and bring things into one benefit portal?’ This was the vision a few years ago and it still is going forward.” —DHS program manager A major problem faced by Rhode Island, and a key reason it was selected for the WSS project, was the policy and operational division between health programs and human services programs, compared with other states Yet Rhode Island’s first WSS activities seemed to focus on just one part of this divided terrain—the human services programs—and paying less attention to the state’s medical programs, RIte Care and CHIP That changed toward the end of the planning year, when the WSS team plunged into the state’s broader effort to prepare for the Affordable Care Act and health insurance exchange implementation One WSS team member was a manager from the Executive Office of Health and Human Services (EOHHS) and she was involved in the initiative and in the state’s health care reform preparations She recognized the need for DHS also to be part of the discussions in the development of the Health Insurance Exchange and the new eligibility system (this effort would come to be known as the United Health Infrastructure Project, or UHIP) Engaging with these efforts proved to be one of the biggest challenges for Rhode Island, senior DHS staff said Moreover, the solutions will have a profound effect on the state’s entire suite of WSS programs 14 Work Support Strategies Rhode Island is part of a consortium of New England states, led by the University of Massachusetts Medical School, that was awarded an “Early Innovator” grant from the U.S Department of Health and Human Services This grant supports states in designing and implementing the information technology infrastructure needed to operate health insurance exchanges Rhode Island began to procure and implement a new eligibility system that would accommodate health reform changes Although this process began during the WSS planning year, the WSS team was not initially involved The original plan for implementing the new eligibility system was broken up into three phases In phase one, the health insurance exchange would be installed and in place by October 2013 In phase two, the new system would replace InRhodes as the state’s Medicaid eligibility system In phase three, which had a target date of 2016, SNAP and cash assistance programs would be added Because the human services programs were not scheduled to be integrated until much later, DHS staff were not included in the early planning sessions for the eligibility system The state was running the risk that the WSS plan, which had been primarily focused on human services programs, UHIP’s eligibility system plan would not fit together “While we were crunching numbers and developing our WSS plan in this room, the health insurance exchange and Medicaid policy people were meeting in another building and were so revved up with a million consultants ready to meet these deadlines, but we weren’t at the table,” said a core WSS team member In the last months of the planning year, Rhode Island decided to integrate the human services programs into the new system earlier, as part of phase two Several factors influenced this decision After discussions with community partners and others, senior members of the WSS leadership team decided that a 2016 DHS integration was too far into the future At the same time, the national WSS team was emphasizing the importance of integrating health reform planning with the WSS initiative, citing close linkages to health reform as a criterion for selecting which states would move on from planning to implementation And the federal government’s decision to provide enhanced resources for integrated eligibility systems was ultimately the driving factor, a senior WSS project member said The state had to integrate all programs into the new system sooner than originally planned or it would miss out on the newly announced federal funding Early Lessons From The Work Support Strategies Initiative: Rhode Island 15 Given the differing goals and timelines for the Health Insurance Exchange, the Medicaid program, and the Department of Human Services, the process wasn’t easy for any of the groups, but senior staffers think the result was worth it “Literally the ground was changing,” a senior project member said “It was a constant challenge and a constant tension between the [two departments] so to speak in lobbying one another.” On the other hand, the WSS team saw big advantages to being involved earlier in the new eligibility system It “will give us a lot of opportunities to say what works right and what doesn’t, and if something doesn’t, let’s fix it in the new system,” one of the state’s core WSS team members said As of March 2012, about two months after the change in plans, Rhode Island was an engaged partner in completing a request for proposals for the new integrated eligibility system , including the participating human services programs Engaging Frontline Workers in a Unionized Context “I really enjoyed this because everybody was involved.” —SNAP caseworker reflecting on the PDSA experience During the planning year, the Rhode Island WSS team experienced successes and challenges in engaging line workers Many are shared by other states, but some were specific to Rhode Island because of the state’s history and unions Line staff responded enthusiastically to the opportunity to help improve efficiency and program effectiveness through local office pilots A common theme voiced by senior Rhode Island WSS staff was the success of business process mapping and redesign activities offered to line workers and managers through the Southern Institute These senior officials thought that previous efforts to implement new policies were sometimes met with skepticism by line workers, but the Southern Institute’s PDSA model disarmed pushback because the caseworkers themselves were planning the new policy Workers agreed A SNAP caseworker said that the PDSA process likely was the first time the state’s eligibility technicians were invited to be a part of developing new policy and decisions about what to change didn’t come from management A line worker assigned to family medical 16 Work Support Strategies applications also praised the process: “Everybody has a piece of this, right on back to the mail room.” In Rhode Island, line workers are part of a union The WSS team met with the union to discuss the Ford initiative and its goals before bringing the PDSA process to the workers Some of the eligibility technicians involved in the PDSAs were local union stewards After participating in the PDSA process, they expressed their support and enthusiasm for the process to the union president and felt she was supportive in return However, other parts of the state’s initial strategy, particularly the idea of bringing programs together by adopting a universal caseworker model, posed challenges Line workers, including eligibility technicians, are assigned to one program and generally not check eligibility or handle application processes across programs, DHS staff said And while DHS administrators and regional managers described the state’s relationship with its public employee unions as generally positive, they felt that efforts to improve cross-program collaboration through a universal caseworker model required ongoing discussions When asked what they thought about switching to a cross-program model, some line workers articulated a willingness to change but others said they were concerned about not getting enough training Workers worried that each program had its own set of rules, required documents, and steps to follow for the application process When line workers were asked if they thought the cross-program model would be possible with sufficient training, several staff responded that a shift was doable but required planning to ensure no one was overburdened picking up the slack of other workers in training While Rhode Island had planned to begin implementing the universal caseworker model in the fourth quarter of the planning year, they postponed the plan to have more time for communication with the unions After further deliberation, senior department staff concluded a transition to the proposed universal model may not bring the desired results At a late point in the planning year, senior staff said they realized that the goals of revamping business processes and pushing for maximum cross-enrollment should be paramount and that the notion of a generic or universal worker need not be a specific goal Rather, the proper deployment and roles of workers Early Lessons From The Work Support Strategies Initiative: Rhode Island 17 would become evident and established as WSS-inspired reforms were studied and begun through the involvement of all levels of the organization The benefits of a process approach to managing cases was advanced through the PDSAs enacted by the department and later became a major policy goal adopted by the WSS team and the state Senior staff said they are confident this is an objective all levels of the department including line staff can work toward despite necessary training and workplace adjustments Given the sharp reductions in staffing due to budget concerns in recent years, administrators also thought that workers might believe cost savings, and not collaboration, was the driver for change A regional manager thought that workers would think that a new process management system and talk of efficiency and cross-program collaboration was a cover to further reduce staffing levels The manager was also worried that workers might assume the change was designed for management to more closely scrutinize how quickly workers processed applications; however, line workers did not independently raise these concerns during our discussions with them Using the Planning Year to Move Past Historical Barriers “When you make changes, you’re afraid you’ll be a failure When you see what works, it makes following through on that change easier.” —WSS team member reflecting on the way the site visits helped the team move forward The national structure of the planning year helped the Rhode Island team create a structure for moving forward They also thought that the fresh perspective from the technical assistance team and the site visits to other states helped them overcome their historical challenges and an entrenched culture The technical assistance offered through the WSS grant was as great, or greater, a factor of success as the cash award itself, several senior DHS officials said One administrator expressed doubt that Rhode Island would have been able to accomplish its goals without the technical assistance “It wasn’t the funding…that was the biggest benefit of the grant; it was the assistance and the knowledge,” one program manager said “Folks will listen to that outside person [the 18 Work Support Strategies way] you may be more apt to listen to your friend but not your parents.…When it’s brought from inside, sometimes the culture will fight it.” Senior DHS officials said that, before the start of WSS, they knew they had to evaluate their business processes and become more efficient, but they weren’t sure how to move forward most effectively until the Southern Institute helped show them the way The state’s core WSS leaders thought that having the Institute visit local offices and help them through the business process mapping was crucial—and in marked contrast to previous efforts at system change That targeted technical assistance eventually led to the PDSAs, including SNAP same-day service Rhode Island also benefitted from regular webinars, consultations with experts, and learning opportunities in other states The concept of receiving outside help was fresh, one respondent said, and the overall assistance bolstered the knowledge to push for change The site visits were a tremendous benefit as Rhode Island carried out its planning-year activities and crafted its action plan Visiting other states that had successfully shaken up equally difficult service delivery problems gave them a sense of hope Other WSS leaders said that visits to other states fostered a better understanding of some technical aspects of policy and ingrained Rhode Island Planning-Year Activities Engaged outside stakeholders, ranging from state legislators to community partners and policy advocates, by including them in WSS planning and advisory committees Convened three WSS-focused subgroups—business process mapping, data analysis, and policy—tasked with identifying challenges to moving forward, proposing policy changes, and identifying components for the state’s action plan Reviewed and compared eligibility and enrollment requirements with the goal of aligning the state’s suite of WSS programs; changes not requiring legislative involvement were sketched out and implemented Conducted major business process assessment of the SNAP and family medical programs, with input from frontline staff, beginning with the Providence office One policy outgrowth on the SNAP side—a pilot to provide same-day service to SNAP applicants—was rolled out statewide later in the planning year A second pilot modified how family medical applications were accepted from third-party resource centers Reviewed existing data and reports and developed new procedures for running reports from the department’s data warehouse and legacy eligibility system Also, identified shortcomings of the existing eligibility system and explored plans for creating automated reports and a data dashboard Analyzed churning rates in the SNAP and child care programs Built close connections with the state’s health reform activities, including representing and advancing DHS programs in the design of a new eligibility system Early Lessons From The Work Support Strategies Initiative: Rhode Island 19 in the core team that changes on their WSS wish list could happen sooner than anticipated Conclusions Rhode Island began the planning year with inefficient and frustrating enrollment processes for work supports, less than desirable participation among eligible residents, a lawsuit over the timeliness of food assistance benefits, and low morale among its eligibility workers and other staff Motivated by these challenges, Rhode Island took specific actions during the WSS planning year aimed at improving client access to benefits, increasing cross-program integration, and making service delivery more efficient First, they engaged frontline workers as well as state leaders and community stakeholders, to bring everyone on board with the WSS efforts Second, the Rhode Island WSS team built close connections with the state’s health reform activities, including representing and advancing DHS programs in the design of a new eligibility system Third, the WSS team conducted new data analyses while reviewing existing data and reports, and identified other opportunities for data system improvements Finally, Rhode Island identified opportunities to align eligibility and enrollment requirements across the state’s suite of WSS programs, and implemented policy changes that could be made directly by the department At the end of the planning year, Rhode Island was awarded a three-year implementation grant from the WSS project Rhode Island’s action plan for the implementation stage describes how the state proposes to make the changes they identified during the planning year Rhode Island’s plan includes implementation of a communications strategy targeted to underserved populations to help them understand WSS programs for which they might be eligible, and implementation of a staff engagement and training strategy to rekindle an agency culture that demonstrates inherent respect for both clients and staff The state also plans to develop a No Wrong Door service delivery model by creating a single application for all WSS programs, reengineering business processes, redesigning DHS lobbies, streamlining policies and procedures across all WSS programs, and utilizing modern technology In addition, Rhode Island’s WSS team proposes to coordinate and integrate its activities with the states’ Health Insurance Exchange to ensure consistency and streamlined access to WSS benefits As part of this next step, Rhode Island expresses its commitment to using data to guide, inform, monitor, and continually improve program participation and service delivery These actions are intended to 20 Work Support Strategies achieve Rhode Island’s vision of increasing timely enrollment, participation, and retention of WSS benefits while reducing administrative costs and burdens Early Lessons From The Work Support Strategies Initiative: Rhode Island 21 References Bureau of Labor Statistics 2012 “Unemployment Rates for States Monthly Rankings Seasonally Adjusted.” Washington, DC: US Department of Labor Cunnyngham, Karen 2012 State Supplemental Nutrition Assistance Program Participation Rates in 2010 Washington, DC: Food and Nutrition Service, USDA http://www.fns.usda.gov/ora/menu/Published/snap/FILES/Participation/Reaching2010.pdf Kaiser Family Foundation 2013 “State Health Facts.org: Medicaid & CHIP.” http://www.statehealthfacts.org/comparecat.jsp?cat=4&rgn=6&rgn=1 Kenney, Genevieve, Victoria Lynch, Michael Huntress, Jennifer Haley, and Nathaniel Anderson 2012 “Medicaid/CHIP Participation among Children and Parents.” Timely Analysis of Health Policy Issues Robert Wood Johnson Foundation http://www.urban.org/UploadedPDF/412719-Medicaid- CHIP-Particip.ation-Among-Children-and-Parents.pdf U.S Census Bureau 2013 “Percent of Individuals for Whom Poverty Status Is Determined Below 200 Percent of Poverty in 2011 From the American Community Survey – 1-Year Estimates.” Washington, DC: US Department of Commerce 22 Work Support Strategies Methodological Note This report is based on several sources, including evaluation team members’ on-site and telephone interviews with Rhode Island WSS team members and others in the state working on WSS and related efforts; WSS materials, including quarterly progress reports and quarterly call notes; and state documents, including the WSS proposal, action plan, presentations, relevant web sites, WSS data exercise results, evaluation documents, and other materials During a four-day visit to Rhode Island in spring 2012, the evaluation team held 13 interviews with the WSS management team, directors of local social service agencies, advocacy organizations, local social service agency staff including union representatives, and state agency leadership and staff from SNAP, child care, and Medicaid programs The goal of this Phase I evaluation was to draw on these sources to document Rhode Island’s activities during the WSS planning year, including the challenges the state encountered and the approaches chosen to overcome those challenges This goal arose from the particular features of the planning year and the nature of the lessons that could be distilled During this phase, states were assessing their current strengths and weaknesses and designing and testing potential next steps, culminating in the development of an action plan (with clear goals and measurable targets for reaching them) From an evaluation perspective, therefore, it was too early to assess whether states had met measurable goals, but not too early to document what actually did happen, what bumps occurred along the way, and how states responded Thus, during the on-site visits, the evaluation team members attempted to gather input from varied perspectives, including local office staff and community stakeholders, but did not attempt to comprehensively gather input from all perspectives in order to evaluate the effectiveness of planning-year activities Six states (Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina) are continuing on to Phase II of the evaluation This next phase has three major goals: to document, understand, and draw lessons from the implementation of WSS activities in the states; to identify and track over time key outcomes that the state would expect to be affected by its activities and interventions; and to measure the effect WSS or specific activities under WSS had on key outcomes To meet these goals, the Phase II evaluation will include implementation analyses and data tracking for all six states, and impact analyses to provide quantitative causal results where feasible Each state’s evaluation will be tailored to its particular activities, goals, priorities, and data availability The overall evaluation will combine information, analyzing data and results from across all six states Early Lessons From The Work Support Strategies Initiative: Rhode Island 23