Jonathan Walters is the Executive Editor of GOVERNING. He has been covering state and local public policy and administration for more than 30 years.E-mail: Jowaz22@gmail.com
When Russ Barron took the administrator job seven years ago, Idaho’s health and welfare services were a mess. Customers were waiting weeks -- in some cases, months -- to receive the cards that would give them access to benefits. It was bad enough that the state was being penalized by the feds for the way the food stamp program was being run. “Even worse,” Barron says, “our employees were blamed for sloppy casework. They were actually doing the best they could. They just didn’t have the right tools to do good casework.”
His first priority was to fix the food stamp application process. To find out the source of the problems, he traveled around the state and stopped in every regional or local office to talk to his employees. The trip turned up basic issues: a 22-year-old eligibility system that didn’t actually help determine eligibility; Byzantine business practices; and a general malaise among staff, most of whom doubted that anything could or would change.
With an eye to solving the problem, Barron asked the Legislature for two things: money for more staff so they could provide short-term relief for customers and money for a new IT system to ensure the long-run effectiveness of the program. The Legislature told Barron that the state could only afford one and left it to him to choose.
Barron took IT. Without a new eligibility system, prospects for the future were hopeless. But he didn’t give up on a short-term booster shot. With his top management team and staff by his side, he took the first steps toward changing the business processes, and with it, the culture at the agency. The first hurdle: getting staff to think in new terms about speed. With food stamps, federal regulations say the state has 30 days to determine eligibility. His staff had been working with that goal in mind, but Barron wanted that whittled down to seven days.
One of the ways to achieve that target has been the reinvention of how citizens apply for benefits. Applicants had been handed a sheet and asked to check off the benefits they wished to apply for -- many of them checking almost every box. “All they know is that they need help, and they want all the help possible,” Barron says. Unfortunately, they often applied for benefits for which they weren’t eligible. Staff couldn’t just erase a check mark. The agency had to do a formal denial that wasted time and meant the state had a high denial rate for benefits, which drew scrutiny from the feds.
Today, a caseworker walks applicants through the process. The goal is to ensure that they are eligible for everything they apply for.
But it is in food stamps where the agency has seen the most dramatic improvement. When Idaho finally flipped the switch on its new eligibility system, the waiting time for a food stamp electronic benefits card virtually evaporated; in most cases, applicants now receive same-day approval and have benefits the next day.
“That was hugely rewarding for our staff,” Barron reports. “They could get their work done, and it was instant gratification as they saw the look on customers’ faces.”
Photo: David Kidd
Maura Corrigan has the equivalent of a large scoreboard outside her office -- a spot well traveled by all her top staff. The board includes more than a dozen goals, from centralizing intake for child abuse and neglect complaints to increasing the number of licensed foster homes statewide and designing a family engagement model.
The scorecard is there in no small part because in 2008 the Department of Human Services (DHS) came under a federal consent decree that contained specific improvements in performance that the state needed to make in providing services for children and families. That decree turned out to be a key reason why Corrigan stepped down from the bench -- she had been a judge on the state Supreme Court -- and took Gov. Rick Snyder up on his offer to head Michigan’s human services programs.
She has focused squarely on the basics -- the state’s woefully outdated information technology system and the problem of chronic understaffing. She has used the money that Snyder made available to hire 800 new staff and to overhaul the DHS IT system, giving caseworkers the tools they need to get out into the neighborhoods where their clients are.
At the same time, Corrigan and her staff have launched two pilot programs focused on helping foster kids succeed well into adulthood. To deal with chronic truancy, Corrigan is putting caseworkers in schools. That way, they can get involved with the whole family, not just the child, since truancy is often the result of problems on the home front. Right now, DHS is working with 19 schools in four troubled cities. The goal is to move into all 135 schools in these cities.
Another pilot program is aimed at recruiting young adults about to age out of foster care for college -- and then seeing them through to graduation. Key to the program is the concept of “campus coaches” -- staff who are on campus and available 24/7. If a student begins to slide into a crisis, there’s help immediately available. It’s an approach based on a painful and fundamental reality, Corrigan says. These are kids who have been taken away from their parents, are legally orphans and are on their own. If they have a problem, they don’t have anybody to call.
The campus coaches’ strategy is starting to pay off. The first group of students, who started in 2008, is on track for a 50 percent graduation rate. Students in the 2009 cohort look like they will do even better, with a nearly 60 percent graduation rate.
Corrigan’s guiding principle for herself and the department is to “make sure the benefits get to the neediest people, and to make people self-sufficient. There are no throw-away kids and no throw-away people.”
Tony Keck, who arrived in South Carolina with the incoming Nikki Haley administration, is working on a handful of high-profile and ambitious initiatives to tame health-care costs -- and still provide quality care. His aim is to find a way to use fee-for-service payments for some services and capitated payments for others. To figure out the best way to implement such a blend, he pulled together a coalition of very large health-care purchasers -- the likes of Boeing, Walmart, General Electric and Verizon.
This isn’t Keck’s only attempt at cost taming. One tool he has been using is to trade a promise not to reduce reimbursement rates in return for a promise to cut usage. That was the tactic he used to cut down on induced premature births when neither the mother’s nor baby’s life was threatened. The babies often ended up needing expensive care in neonatal critical care units. Since 60 percent of premature births are covered by Medicaid, it was costing the state a good deal of money. Keck made a deal with obstetricians: Cut the number of neonatal critical care days, and he’d agree not to cut Medicaid reimbursements for deliveries. So far, it’s working, he says.
Keck is also working to reduce obesity and its many costs to the health-care system. Again, he has pulled together a coalition of 30 organizations, including representatives from Medicaid, BlueCross BlueShield and the state Chamber of Commerce. By having such a broad range of influential members, Keck sees a unique chance to be effective. A member like Boeing, for instance, can work with providers on better health-care management. At the same time, the company can initiate its own preventive health programs internally.
“This has never been done before,” Keck claims. Rather for decades the country has been suffering what Keck colorfully and succinctly describes as “the craziest system where the people who are selling the product are actually the ones generating the demand.”
Joette Katz stepped down as Connecticut Supreme Court Justice in 2011 to take on the job of commissioner of the Connecticut Department of Children and Families (DCF). Since being sworn in, she has worked through a list of changes and improvements to the department that read like a children and family services best-practices manual. For example, to provide ongoing staff training and development statewide, she created a DCF Academy of Family Workforce Development and Knowledge.
Her biggest change was reorganizing the department to undo the silos that decided how clients were handled. “You had a head of behavioral health, a head of child welfare, a head of juvenile justice,” she says. “But it’s the same kid!”
One of her biggest victories has been legislative. She lobbied for and won passage of a law allowing the department to share information about kids and families more easily among state agencies and with key players in the system, including foster parents. “That’s huge,” says Katz. “You’re going to give a foster family a child but you can’t tell them anything about that child, about the kid’s background? People can do amazing things if they’re informed.”
Katz had her eye on another prize too: Bringing foster kids who had been placed out of state back to Connecticut and moving foster children in in-state institutional or congregate care (private residential quarters with shared living and dining space) back into family and community settings.
When Katz arrived, the state was spending 80 percent of its placement money on institutional care and 20 percent on community and foster care. She convened a summit of providers and advocates and made it clear she wanted to flip that ratio. She has also instituted a policy whereby she personally reviews all proposed placements of children under 12 in congregate care.
Bringing kids back to Connecticut proved to be remarkably easy; it was a matter of putting time and energy into the initiative, and also reassuring caseworkers and supervisors that it was OK to take what Katz calls an “educated risk” in placing kids in potentially less secure but also potentially healthier settings. Too many placements, she believes, were a reflexive and defensive maneuver rather than a reflective and active attempt at finding stable, therapeutic, in-state solutions.
She has had success in several age groups. When her agency focused on kids under age 12 in congregate care, the numbers plummeted from 212 a year ago to fewer than 70 today. For kids under age 6, there are now only two in institutional care.
Now, Katz is setting the agency’s focus on 13- to 15-year-olds. Between issues like sexual abuse, mental health problems and involvement with juvenile justice -- along with histories of bouncing from one congregate care setting to another -- it’s a much more difficult cohort, Katz acknowledges. This year, she has been emphasizing building capacity to find and offer specialized clinical services aimed specifically at children with more severe and more complicated problems.
Not all providers have been pleased with Katz’s drive to get kids out of congregate care and into therapeutically proven, community-based programs. “We had 144 [institutional] beds,” says Katz. “So I wasn’t really popular when I said, ‘They’re expensive and I don’t want them.’” The number now is half that.
The push on better placements is part of her fundamental effort to refocus the system on outcomes, whether that means launching a vocational education program for dropouts or ensuring better treatment for kids with severe mental health problems.
As for her commitment to the agency, she ignores the fact that most of those in her position are short-termers. She made a four-year commitment.
Photo: Peter Morenus/University of Connecticut
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