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

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, ineffic

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 do not necessarily reflect those of the Urban Institute, its trustees, or its

funders

Contents

Forging Common Goals among the Health Insurance Exchange, Medicaid Expansion, and

Although Rhode Island offers generous public benefits,

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

low-income 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

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

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

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 Programs Included in Rhode Island’s Planning Year

SNAP: Supplemental Nutrition Assistance

Child Care Assistance Program

RI Works: Rhode Island’s name for

Temporary Assistance for Needy Families

(TANF)

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

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%

Unemployment rate (September 2012):b: 10.5%

Share of eligible residents participating in SNAP (in 2010):c all individuals, 81%; working poor, 63%

Share of eligible children participating in Medicaid (in 2010):d 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: 9

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

Agriculture (2012); d Kenney et al (2012); e Kaiser Family Foundation (2013)

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

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 specific 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

program-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

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

Understanding the “As Is” to Get to the “To Be”

“You have to understand the ‘as-is’ to get to the ‘to-be.’ You have to understand the

application process.”

—Senior DHS official

“One of the things that [was] most refreshing was to take a look at what we are doing and

how we are doing things and how to use data to improve processes…Process improvement isn’t something people have had time to think about, seeing how busy everybody has been

with the day-to-day.”

—WSS leadership team member

An important insight for the Rhode Island WSS team was the recognition that the application processes were not sufficiently documented and how important it was to devote time to

diagnosing the “as is.” The department also lacked data that could have illuminated the situation

on the ground in field offices and shown where the enrollment process could be improved

The WSS team took three steps to better understand how clients and staff navigated the system: mapping policy, observing and piloting processes, and analyzing data First, the state convened a DHS policy subgroup charged with reviewing and aligning key rules among its suite

of WSS programs Group members—including state policy staff, regional managers, training staff, SNAP corrective actions office administrators, and outside community partners—worked together to find common goals, identify quick wins, and achieve a basic understanding of each work support program The group began by building comparison charts for each program with an inventory of eligibility and enrollment requirements Using this inventory, they identified what was and was not a federal requirement, creating a bank of ideas for what to include in Rhode Island’s phase II action plan, staff said “Everyone was thinking different things, so the chart was huge in the beginning,” a core WSS member said Eventually, the group narrowed their focus to

a few eligibility requirements that cut across all programs

The WSS team then catalogued what changes could be made directly through DHS policy and rule-making to align requirements They began identifying quick wins, such as removing some reporting and recertification requirements Finally, the team sketched out the bigger

changes that would require more work to put in place “As with any project, your most important

piece is gathering requirements [about] where you are now and then mapping where you want to go,” a program manager involved in the subcommittee said “You can’t map where you want to

go without seeing where you are.”

The WSS team’s second task, which perhaps led to the most powerful insights, was mapping the application and redetermination processes as they actually occurred in local offices

Participants had a general sense of the administrative challenges facing applicants and recipients

in Rhode Island system, but not a full picture Because the work support programs were

separated, clients had to fill out separate applications for each program (unless they were

applying to RI Works, Rhode Island’s cash assistance program) Further, information taken for one program was not used to help or screen enrollment in other programs The application and recertification processes were often confusing and cumbersome, according to senior DHS

officials and community advocates In the words of one DHS program manager:

“I think what’s tended to happen is that they come in and say they want RIte Care,

and they’re just given an application for RIte Care, and nobody tells them that

they may be eligible for SNAP or possibly cash assistance or child care People

don’t really get that we have so many acronyms and so many programs, and

people don’t understand you have to renew your medical assistance to keep your

health coverage.…We don’t do a great job of educating people up front [about]

what they actually have access to.”

Rhode Island’s WSS team was inspired by a WSS site visit to New Mexico, where they saw entirely different processes in action To evaluate their own processes, Rhode Island took

advantage of technical assistance offered to WSS states by a national nonprofit, the Southern Institute on Children and Families Under the Southern Institute’s guidance, staff from the

central DHS office and local DHS offices walked through the process application in Providence (Rhode Island’s largest field office) The walkthrough demonstrated what clients actually

experienced and gave staff a clearer picture of what problems needed to be fixed

Staffers in local offices were then charged with developing “PDSA” (short for Study-Act) solutions to the problems they had identified The WSS team encouraged those most directly involved not only to implement the solutions but also to plan them out Beyond the technical assistance help, the key players in the process were local office administrators,

Plan-Do-supervisors, and eligibility technicians who had volunteered to participate (The Providence

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