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Establishing a True 'No Wrong Door' Approach to Human Services

To reach all their clients, state human services officials say technology and less rules and regulations are key.

The recurring theme at Governing's Outlook in the States and Localities conference this year was the continuing grim fiscal picture for governments. Pie chart after bar graph after line all graph illustrated the troubling trends that governments are seeing across the board in revenues versus service demands.

While there was some mildly encouraging news about the (slow) recovery of state revenues, the parade of presenters clicking through gloom-and-doom PowerPoint presentations reinforced that the serious fiscal pain would likely last well into 2013 and possibly beyond.

Yet there was a clear subtext to the two-day proceedings that couldn't be ignored, one that highlights the caliber and quality of the best that local, state and federal government leadership has to offer today. That subtext was actually on full display during a conference panel that I moderated on delivering human and health services in these challenging fiscal times.

The posture of the panelists was an interesting and inspiring combination of resignation and determination: Yes, times are tough, but we have a job to do and we're going do everything in our power to get that job done regardless of the circumstances in which we find ourselves.

In fact, what the panelists talked most about was the necessity for operating in the most efficient manner possible these days, a theme that took the "no wrong door" concept of delivering health and human services, and extended it beyond a single office or department.

For starters, panelists agreed, a true no-wrong-door approach to health and human services would be founded on a new definition of poverty that would much more accurately reflect the real cost of living. "We figure it costs a family of four $96,000 a year to live here," noted panelist Uma Ahluwhalia, director of the Montgomery County, Md., Department of Health and Human Services. "But one parent loses their job and suddenly they're down to $35,000 and they still don't meet the definition."

To the extent that individuals do qualify, though, there are still way too many rules and regulations that prevent the easy and sensible sharing of information that would make "no wrong door" more than a hopeful slogan. For efficiency's sake, Ahluwhalia says the county has been working to take an astounding 136 different computer systems and consolidate them into about 10, "but confidentiality rules make integration very difficult; we operate within a very complex grid of policies and rules."

For example, Ahluwhalia said, Montgomery County schools aren't allowed to inform her office of which students qualify for free or subsidized breakfasts, which would likely help the county key in on families that need other services.

While the feds, of course, got their fair share of blame for the maze of rules surrounding programs, it turns out the frustration expressed by officials like Ahluwhalia is shared by federal officials, too. Panelist David Hansell, acting assistant secretary with the Administration for Children and Families (ACF) at the U.S. Department of Health and Human Services, agreed that "confidentiality laws that transcend departmental boundaries don't allow us to operate in the best interests of the client."

Hansell, who has worked in human services in both New York City and New York state, added that the ACF clearly understands that local, state and federal officials need to keep working together in the name of a much less fragmented health and human services system. "We really do want to address issues of efficiency and cooperation," said Hansell, "and we know that program integration and interoperability can now be enabled by technology in a way that wasn't possible before."

As one key step to that goal, said Hansell, ACF is in the process of pursuing what it's calling a "national information architecture domain," the goal of which is to at least create a set of consistent terms and definitions as a basic foundation for future program integration and interoperability.

But the challenges are still stark. Ahluwhalia noted that she'd seen her budget cut every year for the last three years, while at the same time witnessing a more than 100 percent increase in SNAP participation, a 37.2 percent increase in TANF use and a 49.5 percent increase in those accessing Medicaid.

Given those trends, it's obvious, said Ahluwhalia, "that we need a new business model for HHS, and technology is clearly a significant part of the answer." So much so, she says, that despite ongoing cuts to money for front-line services, she is going to carve more than $10 million out of her budget to begin integrating technology systems, an initiative that she sees as absolutely critical to bringing a much more efficient and true no-wrong-door approach to delivering health and human services in Montgomery County.

Elizabeth Daigneau is GOVERNING's managing editor.
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