STATE OF WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES (DHFS) 2005 COMPUTERWORLD HONORS CASE STUDY SUMMARY APPLICATION

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1 SUMMARY STATE OF WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES (DHFS) 2005 COMPUTERWORLD HONORS CASE STUDY GOVERNMENT & NON-PROFIT ORGANIZATIONS IN THE FACE OF BUDGET CUTS AND REVENUE SHORTFALLS, THE STATE ESTABLISHED, DEFINED, AND IMPLEMENTED A SET OF INCREMENTAL SOLUTIONS THAT LEVERAGED BOTH NEW AND EXISTING INVESTMENTS AS WELL AS NEW ADVANCES IN TECHNOLOGY. THESE SOLUTIONS HAVE REDUCED FRONT-LINE WORKERS' WORKLOAD, INCREASED PROGRAM PARTICIPATION, AND IMPROVED WORKERS ABILITY TO SERVE THE STATE SNEEDIEST CITIZENS. [ ] Robert Carrigan, Chairmen of the Chairmen's Committee Ron Milton, Vice-Chairman of the Chairmen's Committee Dan Morrow, Chief Historian Over the last several years, state governments have had to cope with the largest budget shortfalls since the early 20th century while meeting the challenge of maintaining the delivery of quality services to its citizens. As a result of this budgetary pressure, Wisconsin s Department of Health and Family Services (DHFS) was forced to cut reimbursement funds to local agencies that administer its Medicaid and FoodShare (federally known as the Food Stamp program) programs at a time when participation in these programs was increasing (70% increase in recipient participation from January 2000 to January 2005). These crucial programs support some of the neediest citizens by providing them with access to basic medical and food support. As a strategy to offset this reduction in funds, DHFS developed a plan to work with local agencies to achieve a reduction in staff workload so those agencies could continue to be able to serve citizens. DHFS established, defined, and implemented a set of incremental solutions that leveraged both new and existing investments as well as new advances in technology. These solutions have reduced front-line workers' workload, increased program participation, and improved workers ability to serve the neediest of Wisconsin s citizens. APPLICATION DHFS determined that its use of information technology could be optimized to better serve its citizens and provide an integrated set of IT tools to front-line workers. DHFS charted a strategic plan with the assistance of Deloitte Consulting LLP to meet their business goals and objectives. The strategic plan consisted of a threepronged approach to reduce local agency workloads based on an analysis of how citizens interacted with local agency workers and how local agency workers interacted with the IT tools provided by DHFS. DHFS accomplished the implementation of their strategy in just over a year and a half. First, it developed an integrated web-based (J2EE) multi-lingual screening tool called ACCESS: Access to Eligibility Support Services for Health and Nutrition. In its current form, ACCESS provides users with a simple 15-minute self-assessment of potential eligibility for FoodShare, Medicaid, BadgerCare, SeniorCare, WIC (Women, Infants and Children), school meals, summer food programs, The Emergency Food Assistance Program, and tax credits for low-income households. ACCESS uses a short, interactive web page flow to help low-income families, pregnant women, people with disabilities, senior citizens, and others to determine their potential eligibility for health and nutrition programs. It also provides immediate and specific information about how to formally apply for benefits in their county. While many low-income residents use ACCESS on their own, community-based organizations like food pantries and health clinics also use ACCESS to assist their clients. Future enhancements to ACCESS, currently in development, will allow Wisconsin residents to apply online for benefits, get personalized information about existing benefits, and update their case information online. These enhancements will ease the workload for local agencies by reducing the need for direct contact with front-line workers. Second, after discovering that front-line workers spend an inordinate amount of time filing, searching for, and returning paper-based verifications and application forms required by current program policies, DHFS decided to automate this process. Using IBM s Content Manager scanning/imaging technology, DHFS centralized receipt of some verification documents and also started converting current paper-based case files to a paperless Electronic Case File (ECF) system. Front-line workers can now easily pull up citizens case documents via their desktop. This reduces the need for citizens to provide new verification materials when they move from one local agency s service area to another or when DHFS staff complete reviews to assure that eligibility has been determined correctly. The ECF has been rolled out in three pilot counties representing over 27,000 cases. ECF will be implemented throughout the rest of the state this year. In future phases, ECF will be implemented at regional change centers. Some consortiums of counties have created these change centers to process citizen-reported changes. These change centers will benefit from this anytime,

2 anywhere access to citizen s case files via ECF. Additionally, DHFS has made a concentrated effort to administer some benefit programs and certain processes centrally specifically, those that make sense from a business perspective. They use an in-box module that is integrated with the State s case management system CARES (Client Assistance for Re-employment and Economic Support). This inbox module routes centrally scanned employment verification forms and prescription drug benefit applications (scanned using Optical Character Recognition (OCR) to capture form data) to assigned workers. This has reduced the need for workers to process as much mail and also reduced the time workers spend contacting and returning documents to citizens. Third, DHFS determined that its current case management and eligibility system, CARES, needed to be modernized. CARES is a COBOL/IMS/DB2-based system that has been expanded and modified to accommodate changing federal and state public assistance program requirements for the last 12 years. Local agency workers use over 800 mainframe transactions, each with a special four-character code to determine eligibility and manage their cases. Workers must memorize a multitude of codes to enter into various screen fields. Although the system had changed over time to satisfy business and policy needs, its user interface was limited by its green-screen mainframe restrictions and the system had become increasingly more expensive for the state to operate and maintain. DHFS wanted to address many current CARES limitations/issues as part of their strategic plan. One issue was the significant and costly training workers required in order to learn how to use CARES. Another issue was that incorrectly entered data often resulted in incorrect eligibility determinations. DHFS also believed that a portion of local agency worker turnover was directly attributable to the complexity of the green-screen user interface. Additionally, the system was not sophisticated enough to limit which questions were being asked of applicants and recipients, even when these questions were not relevant to determining requested program eligibility. This model contributed to the workload of local agency workers and the time required of citizens to complete the application process. In February 2005, the State of Wisconsin went live with Project One of CARES Worker Web (CWW). CWW is the first incrementally implemented, state-of-the-art, J2EE IBM WebSphere/Mainframe DB2 eligibility and case management system in the country. Project One of CWW involved the research, requirements, design, development, and implementation of over 120 web pages that replace most of CARES data-entry transactions (approximately 40% of the CARES transaction volume). CWW is architected with intelligent data collection which, based on program eligibility rules and case members program requests, reduces the number of questions workers need to ask clients. Additionally, as part of the CWW rollout, DHFS improved front-line workers' ability to quickly resolve problems on their own by streamlining all of its worker support material and making it available online. Using Macromedia s RoboInfo product, DHFS developed System Help for CWW, revamped and improved its Medicaid and FoodShare policy help, and consolidated all its process-related help. Previously, process-related help had been scattered across multiple storage locations and was not accessible electronically. BENEFITS ACCESS, ECF, and CWW are revolutionizing how Wisconsin s front-line workers perform their jobs, thereby saving them valuable time, and improving citizen service and access to government assistance. Simply stated, Wisconsin s front-line workers are able to continue to serve its neediest citizens despite budget cuts that have forced a reduction in the number of front-line workers available. Since ACCESS launch in mid-august 2004, more than 15,000 people have visited the website. More than 10,000 households, or 89% of those who complete the screening, appear to be eligible for at least one program. Each week, over 200 people who apply for benefits report that they have used ACCESS before coming in to apply for FoodShare or Medicaid. Additionally, by providing information about programs like tax credits and school meals, ACCESS has become an integrated gateway for low-income families who need assistance. Service providers and low-income residents of Wisconsin have praised ACCESS for its simplicity and clarity when dealing with complex and often intimidating benefit programs. Following are selected comments from the send comments feature of the website: This is a fantastic program. It s usually so intimidating to figure all this stuff out and this website helps so much! Thank you, thank you. This is a great web site and I would recommend it to anyone. I am not very computer literate and this form

3 was one of the easiest and self explanitory forms that I have ever seen. Thank you for offering this service to the people of Wisconsin. It really is a great service and it also kind of takes the edge off of not knowing wether or not it would be a complete waste of time to apply or make an appointment at an appropropriate agency. Again Thank you and have a great day. While the ACCESS screener s primary goal is to increase program participation by helping low-income Wisconsin residents learn more about their potential eligibility, it also has tangible benefits for front-line workers. ACCESS helps applicants understand and prepare for the types of questions they will be asked during a formal application interview, as well as the verifications they will need to complete the application process. The website uses conversational language and is written at a 4th grade reading level to make it easier for low-income citizens to use. It uses simple graphics, intelligence to ask appropriate questions, and a great deal of white space to make the pages clear and easy to use. Future enhancements will allow people throughout Wisconsin to apply for and manage their benefits online, will significantly streamline the application process, and reduce their need for direct face-to-face contact with front-line workers. The Electronic Case File (ECF) system and CARES inbox module have helped reduce the amount of time workers spend filing and retrieving citizen s documents and applications. This gives workers more time to deal with citizens issues and service new requests for help. Additionally, DHFS approach to centralized processing of certain benefit programs using scanning/imaging technology has also reduced the need for local agencies to administer programs that would have put additional strain on their delivery capacity. It is anticipated that each worker will save five minutes of time for every case each year. With nearly 300,000 cases, this is a savings of nearly $875,000 each year. Highlighted benefits from the CWW system include reducing the amount of time workers need to process their case activities, requiring workers to ask fewer questions, and reducing the number of screens and codes they need to remember. CWW was also designed for the different types of end users and business flows found in local agencies. Due to the CWW design, receptionists (who generally register clients) and front line workers (who perform application entry and case reviews) can easily determine what pages and fields to use. This will allow local agencies to streamline their business processes, thereby saving time and reducing confusion and errors. Features such as new inquiry pages, sorting, and merging of similar CARES screens in CWW have resulted in improved usability. DHFS anticipates an annual savings of $1.5 million with the CWW. IMPORTANCE DHFS efforts to move its service delivery organization into the 21st century with the use of new technologies has allowed it to continue serve the state s neediest citizens in the face of reduce funding. By creating a direct, effective link between low-income consumers and public benefits programs, ACCESS has helped Wisconsin assist more of its most vulnerable residents. In the next 18 months, it will strengthen this link by allowing clients to apply, report changes, and inquire about their benefits without needing to contact a worker. The benefits of the ECF scanning/imaging technology include reducing the need for error-prone, paper-based processes that hinge on the location of case documents (which not only move between counties, but are assigned and reassigned between workers in the same county) and providing anytime, anywhere access to client s case files to improve service. Lastly, CWW is the platform by which workers manage their workloads and respond to customer inquiries. Its intuitive design makes it easy to learn and reduces training time for new workers. Use of web services has seamlessly integrated CWW with other state agencies to help verify citizens information, as well as reduce fraud and improve overall program effectiveness. All of these technologies, and DHFS integrated vision of how they will operate, have allowed it to continue to provide quality service to the state s citizens. The effective use of these technologies have been a critical factor in enabling multi-channeled access to social services as envisioned in DHFS strategic plan. ORIGINALITY There are number of facets of DHFS vision that are original. The use of electronic scanning/imaging of documents in ECF has been used in many arenas in the private sector, but is not widely used in a health and human service environment. The Electronic Case File, in combination with CARES Inbox module, has given DHFS much more flexibility in how it decides to administer current and new programs in the most cost effective manner. It has helped reduce costs, reduce front-line worker workloads, and streamline communication with clients. DHFS has been able to centrally administer some programs, like its SeniorCare program which provides prescription drug coverage to seniors, further removing workload for front-line workers.

4 DHFS was also original in how it sought feedback from counties before, during, and after CWW s rollout. DHFS developed a detailed End User Feedback web site. This site served as a repository of CWW details for front-line workers to review and provide comments during early stages of the project before all design decisions were made. Details included proposed mock-ups of new pages, new process-related changes, and many pointed questions about specific functionality that gave opportunities for workers to provide input. Many of the comments submitted through the End User Feedback website were incorporated into CWW and the site instilled a sense of ownership and anticipation by workers in relation to CWW. The state has decided to use the End User Feedback site for feedback on future enhancements. DHFS also reached out to low-income residents and community based organizations when developing ACCESS. This allowed DHFS to identify the most critical design features for end users, and encouraged a sense of ownership and interest within these critical stakeholder groups. Another aspect of originality was DHFS incremental approach to rolling out CWW which had multiple benefits. First, DHFS was able to continue to leverage its existing CARES system while starting to move a subset of CARES screens into CWW that would have the greatest benefit being webified into a CWW page. While other states have decided to replace entire systems, DHFS chose to keep a CARES system that works very well in determining program eligibility and only modify the portion that had become obsolete - the user interface. This was key to allowing DHFS to move forward with its vision of modernizing workers tools with tight spending budgets. Second, still keeping cost in mind, DHFS designed ACCESS and CWW in tandem using the same technology platform, which allowed it to leverage much of the code components used in developing ACCESS as a basis for the CWW system this further reduced the cost of implementing the more extensive CWW system. Third, only moving a portion of CARES into CWW was easier for front-line workers to accept and handle versus utilizing a big-bang approach of moving everything into CWW at once. Lastly, DHFS minimized other CARES spending and change requests in order to make CWW a reality without the request of additional funding. SUCCESS With the successful implementation of DHFS strategic plan, front-line workers spend less time processing each application and are more accessible and responsive to new and existing citizen requests for help in local offices. DHFS has tentatively estimated the annual workload savings of just ECF and CWW to be over $2.25 million in worker time. Future phases of ACCESS will allow citizens to apply online, allowing DHFS to garner greater worker time savings and better support the state s citizens. ACCESS has also helped fuel greater program participation which was another goal of the system. Wisconsin is being recognized by the federal government for better program participation. Additionally, national studies have shown that for every $5.00 in Food Stamp benefits received by a state resident, there is an average $9.72 benefit to a state's economy. In the case of DHFS neediest clients, a loss of benefits can be a life challenge, not just an inconvenience that it may be to other citizens. DHFS clients rely on their Medicaid coverage to get much needed medicines and support, and many low-income individual depend on the food provisions provided by Wisconsin s FoodShare program. DHFS effort to reduce front-line worker s workloads through its incremental approach has allowed Wisconsin to continue to serve these neediest of citizens in the face of reduced funding. DIFFICULTY Due to budget cuts, DHFS didn t have the funding to seek out a vendor to complete a full replacement of the CARES system, which could easily cost $40+ million. DHFS analyzed where it could get the best value for its dollar. It mapped out an incremental approach that made the most economical sense where portions of the CARES system would be webified, leaving other CARES functionality (including the DB2 database system) on the mainframe. Strategies, such as not moving the database system to a new relational database platform, eliminated the need for costly data conversion effort. At the same time this allowed DHFS to continue to leverage its existing investment in the mainframe CARES system while addressing critical issues by augmenting it with CWW. In addition to the budgetary issues, DHFS had to lead a multi-department coalition to achieve success which requires a much higher degree of cooperation and coordination. All the new applications (ACCESS, ECF, and CWW) are hosted and maintained by a different department (the Department of Administration), and the base CARES system is jointly managed with the Department of Workforce Development. DHFS needed to consistently manage the input and concern of its state partners as it moved forward with its vision to reduce its local partners workloads. Lastly, DHFS has a diverse delivery organization for its benefit programs including over 4,000 workers,

5 managers, and support staff in 80 different county and tribal agencies. Each local agency manages its own network infrastructure and desktop computers. DHFS needed to coordinate and prepare each of the local agencies for handling the technology requirements for ECF and CWW. Additionally, each local agency needed to be prepared for the impact of CWW to its current business process, as well as have their staffed trained on the new system. Due to budget constraints, DHFS is utilizing a distance learning approach for its training and applying lessons learned from its initial pilot counties.