Piles of paper used to build up on Lorenzo Lewis Jr.’s desk. Applications for cash assistance. Mailed notices about changes in income. Renewal forms. As a public assistance caseworker in Hartford, Conn., Lewis had the job of combing through it all, which he tried to do whenever he wasn’t taking phone calls from clients asking why they hadn’t yet received their benefits. He was perpetually in catch-up mode.
Lewis understands well the frustrations of citizens turning to the government for help. As a boy, he would come with his family to a similar office in Hartford to apply for food stamps. He remembers the booklets—now replaced by electronic benefit transfer debit cards—with colorful paper coupons. “It looked like island money” or some other foreign currency, he recalls. With those memories informing his work, Lewis has always tried to treat his clients as he would a childhood friend or family member. No one should feel judged, he says. Built like a linebacker, Lewis fills up a quarter of his small, undecorated, white cubicle. As he goes through a battery of questions with a woman hoping to qualify for family cash assistance, he is sure to make eye contact with each question.
Despite his sincere personal investment in the work, Lewis’ place of employment has a history of dysfunction. The federal government ranked Connecticut’s Department of Social Services last in timeliness for processing food stamp applications in 2012. In recent years, the agency’s payment error rate for food stamps hovered above 6 percent—about twice the national average—resulting in federal financial sanctions. In May, a U.S. District Court judge granted a preliminary injunction against the agency for losing paperwork and taking too long to process food stamp claims. As of July, a similar lawsuit over Medicaid applications was pending.
Although Connecticut might be the extreme example, its problems represent a now common dilemma for any state or local agency serving the poor: How do you help more people in less time with a smaller staff and budget? One common answer these days is technological—automated call centers, self-service applications online and improved electronic databases, all of which should reduce some of the burden on staff.
But some reformers argue that the most effective approach is also the most low-tech one. A simple reconfiguration of business practices is all it takes, they say. So the Connecticut Department of Social Services, starting with Lewis’ Hartford office, is now trying a more streamlined approach. In the new model, caseworkers specialize in tasks and share clients across an entire office rather than plodding along one-on-one as has been standard practice from time immemorial. And there is evidence that it’s working.
The Hartford field office started using task sharing this spring. In late March, before the change, caseworkers reported a backlog of 20,084 unfinished applications—some dating back to 2009.Ninety days into the reformed model, that backlog had evaporated to zero. Meanwhile, the percentage of emergency applications for food stamps completed on time rose from 64 percent in September 2012 to 77 percent in June. Today, piles of paper no longer clutter Lewis’ desk, and the 11 remaining offices in the state—working with a national consulting firm—are scheduled to adopt the same changes within the year.
Midway through the recession, a new type of applicant appeared in the Hartford lobby: people from affluent suburbs like New Canaan, Simsbury and Avon; people who had recently been employed in real estate or construction; people with 401(k) savings accounts; people with little-to-no prior experience asking the government for help. In the past five years, demand for food stamps across the state has nearly doubled (see “A SNAP Decision,” page 58); for Medicaid, it is up about a third. At the same time, the agency in charge of the state’s safety net programs—food stamps, child care, family cash assistance—shed about 20 percent of its staff through layoffs and early retirement incentives. Even with expanded use of overtime, the spike in applications left the remaining caseworkers drowning. The situation called for a change.
Up until March—and for the better part of the past 40 years—the Connecticut Social Services Department operated on the same basic case management model as most states and localities. A person hoping to qualify for benefits would come into the lobby, fill out a form and wait to meet with an assigned caseworker. Oftentimes the caseworker would be booked all day with prior appointments—a consequence of people not bringing in all the required paperwork the first time around. Backlogs would grow and keep growing. The traditional case management model worked fine when fewer people needed public assistance, says Roderick Bremby, Connecticut’s commissioner of social services. For today’s needs, the old way of doing business is too time-intensive and linear, with an over-reliance on paper and face-to-face interactions.
Under the “task-based” approach, stages of the benefit application process get divided among caseworkers. For simplicity’s sake, imagine a hypothetical office with 40 caseworkers, all previously trained to interview a client, determine eligibility and update benefits as the client’s economic situation changed over time. Now imagine that the group of caseworkers becomes four teams of 10, each specializing in a stage of the process: initial applications, incomplete applications, renewals, or documented life changes that could affect benefits, such as fluctuations in income. Because the caseworkers specialize in one task, they work faster. Working faster, they stay on top of applications. And because the application flow is under control, managers have more flexibility to move workers around as the situation dictates. In the event of a surge, in which new applications suddenly outnumber renewals, for instance, supervisors can temporarily reallocate caseworkers from other teams. With the office free of the one-caseworker-one-client model of operating, clients don’t have to wait for an assigned caseworker. Instead, they can meet with whichever caseworker is free that day, and more are free now thanks to an under-control workload.
Meanwhile, the re-engineering of casework has led to a much more accurate picture of how the office is doing when it comes to timeliness. Under the old system, the caseworker’s schedule dictated how quickly a client would receive services. If a caseworker was out sick, on vacation or booked with prior appointments, other caseworkers typically couldn’t pick up the slack. Even if the system allowed for such flexibility, everyone was usually too swamped to step in. So caseworkers fell behind. In Hartford, when caseworkers fell behind, which most invariably did, they had no incentive to tell supervisors. To do so would only reveal their inability to finish cases in a timely fashion. As a result, no one knew how many cases were being cleared before the federal government’s mandated deadlines. And so in the case of food stamps, for example, it would typically be 30 days before a supervisor knew a case was behind schedule, which put it squarely on the feds’ radar.
That dynamic changed when the cases became the responsibility of the entire office. Tracking became easier because cases were handled in batches. Meanwhile, any delays were the entire team’s delays, not blemishes on one caseworker’s record. Now in Hartford, supervisors hold morning “huddles” with team leaders, where they get updates on staffing, volume of outstanding work and how much was processed the day before. ”When I first got here, it was a mess,” says Lisa Wells, who became a supervisor at the Hartford office last November. “Today it’s leaner, more organized, more seamless—it’s just not chaotic anymore.”
The concept behind the task-based approach isn’t unique to Hartford. A report by the Urban Institute in 2010 analyzed process improvements in the eight states plus the District of Columbia that were experimenting with some form of the task-based approach. The shift to tasks is part of a broader movement to reexamine business processes within health and human services, says Uma Ahluwalia, director of Health and Human Services in Montgomery County, Md. A longtime advocate of smoothing out and integrating delivery of services, Ahluwalia argues that there are plenty of opportunities for doing that, it just takes a little observation and action. One small example from her shop: Staff noticed that employees were losing time waiting to print documents because of long print-job queues. By simply adding a few extra printers, they eliminated delays. “You look at every single step,” says Ahluwalia, “Should we keep this, or is there another way that this step can be completed that is either more manpower- or time-efficient?”
The rewards, meanwhile, go beyond quantifiable efficiencies. First and most obvious, people in need are getting help faster. But it’s also a boon to office morale, says Valerie Nitti, who oversaw the transition to a task-based approach at the Tioga County Department of Social Services in upstate New York. As in Connecticut, Tioga County saw an uptick in demand for Medicaid and food stamps as a result of the recession, along with pressure on resources to deal with the increase. “The caseloads were starting to get absolutely unmanageable,” says Nitti. “My staff was coming in here, working all day and working hard, but it just seemed like they were never caught up. I mean, they were crying at night.” In Tioga’s case, Nitti put together an in-house group to investigate and implement more efficient ways to do business. Under its version of a task-based model, which it adopted in 2010, Tioga County finishes more than 99 percent of its food stamp cases within the federally required deadlines. Employees leave the office knowing they don’t have a backlog of cases to face the next morning. “They can walk out the door,” Nitti says, “with a sense of accomplishment.”
Adjustments to business processes don’t fully explain the new efficiency within the Hartford field office. At roughly the same time that Connecticut was adopting its new way of doing casework, the state added customer service call centers, document imaging software and a Web portal that allows people to submit their applications online. Automated systems are clearly part of the reason caseworkers are processing applications in less time. Modernization in the agency also gives caseworkers new tools for looking up files quickly online, and the problem of lost paper files is rapidly being solved.
Indeed, technology is perhaps the biggest recommendation in favor of the task-based model. The Affordable Care Act will provide federal money to update state technology for accepting, tracking and updating applications online for Medicaid in 2014, and experts argue that it makes no sense to apply new tech to the old one-on-one way of doing business. Taking efficiency another huge step further, many states plan to integrate their health-care application systems with food stamps, cash assistance and other public benefits. If all goes as planned, people in the near future should be able to fill out one form—either online or in person—and apply for multiple programs simultaneously, both in health and human services.
Of course, no one in Hartford is calling its package of reforms a panacea. As of May, about 19 percent of regular food stamp applications still took longer than 30 days to process. That’s about the same as in September of last year. Some believe the real solution ought to be an increase in staff commensurate with the increased number of residents asking for benefits. “The processing and technology changes, they’re good and we support them fully,” says Sheldon Toubman, an attorney with the New Haven Legal Assistance Association, which is suing the department over Medicaid applications. “My opinion is that they are trying to make a change, but they’re unwilling to even talk about the need for further hiring of staff.” Toubman notes that even though the Department of Social Services hired 220 employees in the past two years, the additions merely restored department staffing to its 2003 level.
The task-based approach does have its critics. A recent study by Mathematica Policy Research, a nonpartisan health and human services research organization, looked at states that had revised their food stamp application processes and found that some caseworkers felt disconnected from their clients when they moved to a task-based approach.* Some clients also noted dissatisfaction. “They wanted to be able to call ‘my caseworker,’” says Lara Hulsey, a senior researcher at Mathematica. “And they no longer had a ‘my caseworker.’” The change can be scary for clients accustomed to working with one person through the benefits application process, says Lisa Grunigen, a supervisor at a social service office in Manchester, Conn., which is shifting away from traditional case management. “Some people call their caseworker before they call 911,” she says. “You’re their lifeline.”
Lorenzo Lewis, the caseworker in Hartford, understands those concerns and acknowledges that the human connection is a key reason he got involved in social work. He wants to know he’s helping people who need it. On the other hand, he also wants to do the job well. Lost paperwork and long delays only add up to poor service and lost confidence in the agency. “I want to be effective,” he says. “The satisfaction comes from helping people.”
*Correction: A previous version of this story identified Mathematica Policy Research as a nonprofit organization. It is for-profit.