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
Rhode Island’s Goals for the Planning Year
1
State Background
2
Using Personal Outreach to Bring Everyone on Board
4
Understanding the “As Is” to Get to the “To Be”
7
Striving To Build Structure and Forward Movement
12
Forging Common Goals among the Health Insurance Exchange, Medicaid Expansion, and
Human Services
14
Engaging Frontline Workers in a Unionized Context
16
Using the Planning Year to Move Past Historical Barriers
18
Conclusions
20
References
22
Methodological Note
23
Although Rhode Island offers generous public benefits,
Work Support Strategies
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 lowincome 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 (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.
Early Lessons From The Work Support Strategies Initiative: Rhode Island
1
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
Work Support Programs
Included in Rhode Island’s
Planning Year
SNAP: Supplemental Nutrition Assistance
Program
RIte Care: Rhode Island’s name for family
Medicaid
CHIP: Children’s Health Insurance
Program
Child Care Assistance Program
RI Works: Rhode Island’s name for
Temporary Assistance for Needy Families
(TANF)
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
2
Work Support Strategies
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%
b
Unemployment rate (September 2012): : 10.5%
Share of eligible residents participating in SNAP (in 2010):c all individuals, 81%; working poor, 63%
d
Share of eligible children participating in Medicaid (in 2010): 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
Sources: a U.S. Census Bureau (2011 estimates); b Bureau of Labor Statistics (2012); c U.S. Department of
Agriculture (2012); d Kenney et al. (2012); e Kaiser Family Foundation (2013).
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.
Early Lessons From The Work Support Strategies Initiative: Rhode Island
3
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
4
Work Support Strategies
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 programspecific 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
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
Early Lessons From The Work Support Strategies Initiative: Rhode Island
5
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.
6
Work Support Strategies
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
Early Lessons From The Work Support Strategies Initiative: Rhode Island
7
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 Plan-DoStudy-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,
supervisors, and eligibility technicians who had volunteered to participate. (The Providence
8
Work Support Strategies
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
Early Lessons From The Work Support Strategies Initiative: Rhode Island
9
Plan-Do-Study-Act in Providence
Providence used the Plan-Do-Study-Act (PDSA) strategy to test and implement same-day service to SNAP
applicants. With the traditional process, applicants came in to the office to fill out paperwork and schedule a
time to return for an interview before receiving benefits. In the pilot, at least one SNAP worker was
dedicated to processing SNAP cases right away so that applicants could enroll and leave with an EBT card in
their first visit. “The first client…was like, ‘This is amazing,’” a SNAP line manager from Providence said.
“People tell clients you have to wait weeks for benefits and he walked out the same day with an EBT card.”
Partway through the day, SNAP workers doing same-day processing switched back to traditional
applications. DHS officials reported that the pilot definitively showed that application processing had been
improved. With same-day service, the number of pending cases dropped by about half and workers
reported better control over applications and pending applications. “We… noticed a huge decline in foot
traffic in offices,” a DHS regional office manager said. Under the “old system …we may see you four times,
now it’s once.”
A second PDSA aimed to reduce the number of incomplete applications coming in to DHS offices from family
resource centers. At these centers, which are located in hospitals or other medical facilities, family medical
eligibility technicians help families complete benefit applications. Technicians were urged to forward the
applications to DHS offices within two to three days, but the applications were often incomplete. Under the
revised process, technicians were instructed to hold on to applications for five to six days, giving applicants
more time to bring in missing documentation. The revised process saved DHS workers the burden of
handling incomplete applications and reduced the burden on applicants of bringing missing documentation
to the DHS office rather than back to the family resource center. This effort was begun as a pilot but was
suspended due to disagreements involving worker job function and contractual agreements.
team member said. “It’s not quite as flexible as it needs to be and not quite as easy to get data as
you might like.” Many system reports must still be distributed in paper form, even though the
department is trying to switch to an electronic system. The old system also has no mechanism to
share recipient data between programs and therefore cannot make cross-program data available
(for example, data to evaluate if clients as a whole were encountering common barriers to
maintaining access). Officials said that, despite these challenges, InRhodes possesses positive
aspects that ought to be recognized in a plan for a new platform, but their immediate challenge
was to find and use data to diagnose problems and design solutions.
The WSS team found that Rhode Island had organizational and practical difficulties using
what data it had. As one senior DHS official said: “We realized we had data but couldn’t get to
it. We then realized there’s a new data warehouse, but the warehouse wasn’t able to answer the
questions that we presented.”
The problem boiled down to having lots of data but no efficient and timely methods for
pulling them together. Early efforts to pull the data together proved costly and time-consuming.
10
Work Support Strategies
Rhode Island contracts with a vendor for its data warehouse. The department must go through
the vendor to compile and present data, adding layers of permission to get through to run queries.
The legacy eligibility system coupled with the state’s reliance on a vendor for access to data
made it difficult to get comparable reports over time, a senior DHS official explained. Also, the
silos among programs extended to the data warehouse: even though the warehouse contained
data fields across programs, fields for one program will not automatically show up for another
program and must be manually requested.
Despite these obstacles, the WSS team successfully gathered data to understand several key
aspects of the process that had never before been analyzed. Most dramatic was their analysis of
churning in SNAP and child care. Eligible participants were frequently dropping out of these
programs and then reapplying a short time later, indicating that they had not properly renewed
their benefits. Churning causes families to lose needed benefits in the interim and can be a waste
of time and money for states, as workers must reopen cases and reenroll clients.
SNAP churning had not been analyzed in the past because the state’s data system was not
programmed for this analysis. After performing a one-time analysis in the WSS planning year,
senior managers including the DHS director found the results eye-opening. “The data that was
pulled, the churning, that was something I probably had never looked at, and that was something
important to recognize and see,” one senior program manager said. “It was very interesting.”
The WSS team analyzed churning in the child care program because preliminary numbers
raised concerns, according to a core member of Rhode Island’s team. “The churning data
confirmed we have the smallest program with the largest churn in it. That’s a big glaring red
flag.” The requirement that customers provide actual work schedules was contributing to
churning, as these schedules often are difficult for clients to provide. When clients did not turn in
work schedules, “you ended up with unnecessary denials, which infuriated everyone and led to
administrative hearings, which then took up…time,” a core member of Rhode Island’s team said.
Senior leaders said they also were enlightened by cross-program participation data and data
on timeliness. The cross-program data “was very helpful to us,” a senior program manager said.
“It allowed us to ask what’s missing. Why are some recipients receiving one benefit but not
another? Or why are staff doing such a thing to miss a certain population?” By more clearly
Early Lessons From The Work Support Strategies Initiative: Rhode Island
11
understanding the source of the problem, the state could begin to think concretely about how to
fix it.
The state’s study of timeliness data prompted a more careful look at barriers to providing
service to recipients. The team then discussed potential rule changes and modifications to office
procedures and staff activities that could speed up service. This analysis prompted the DHS
administration to consider what was duplicative and unnecessarily burdensome to clients, thus
causing delays in the system. The question helped state staff gain a new perspective on
verifications: adding more to ensure clients aren’t cheating the system adds unnecessarily to staff
workloads, costs, and delays. As a senior member of the WSS team said, “That was a big one
that helped us strip away things to the basics. We were over-verifying, and we used data to help
support the removal of some program requirements.”
Looking toward the future, DHS staffers see further improvements in the state’s capacity to
gather and analyze data. The health insurance exchange and new eligibility system are expected
to help, as are planned future enhancements to the still-new data warehouse. A data dashboard, a
tool for compiling data electronically, was about 65 percent complete by the end of the state’s
WSS planning year. The dashboard will be more powerful and useful in generating data reports
than the current ad hoc queries and it can be expanded after it is implemented to yield more data
points.
Striving to Build Structure and Forward Movement
“We did a little bit of a work plan, we had some presentations, we did a lot of research here
and there, but it wasn’t directed to any one place.”
—WSS team member describing the challenges of a pre-WSS initiative,
the Modernization Initiative
Past experience in Rhode Island suggested challenges in turning good ideas into actual, fully
implemented change. Staff reported that past efforts to streamline or improve access saw few
policies make it out of the planning stage. The Modernization Initiative, the most recent preWSS initiative along these lines, was criticized by some who had a formal role in its activities for
12
Work Support Strategies
lacking direction and failing to accomplish its goals. Staff reported that other earlier initiatives,
such as a universal application for all programs, were never implemented.
During the WSS planning year, the Rhode Island team worked hard to change this pattern.
Sometimes, the choices that represented important project strengths also posed challenges,
especially in a small, thinly staffed state. For example, as noted earlier, Director Powell
appointed a DHS associate director as project lead, signaling the importance she placed on the
project. But because the state was behind in hiring an outside project manager to support the lead
as originally intended, the associate director also played that role for most of the year. This
arrangement ensured high-level attention but potentially risked bottlenecks given all the other
important priorities senior staff had to attend to.
Staff in general reported that they tried to manage the project’s sometimes frenzied pace
through clear structure and group accountability. One WSS staffer said it was frustrating being
unable to follow through on every area in need of change. Because of the time crunch, policy
areas that ideally would have been considered had to be narrowed in focus, staff reported,
leaving some potential activities unexamined. Team members also reported feeling nervous a
few months after the project kickoff. One core member of the WSS team said learning to accept
feeling overwhelmed was the most difficult aspect of the project. Despite this nervousness, the
WSS team rose to the challenge and stayed on track toward the goal.
Overall, staff reported that WSS succeeded in several important ways dealing with project
structure, in contrast to past initiatives. They found that the administrative structure of the
national WSS project, which included monthly technical assistance check-in calls and required
assessments and data exercises, added focus and kept Rhode Island’s project team moving
forward. Monthly and quarterly check-ins broke the planning year up into more manageable
pieces and kept the team on task as they worked to complete certain steps before the next checkin. “I loved the monthly phone calls, I love the agenda, and I think it keeps people thinking,” a
core WSS manager said. WSS technical assistance offered help and outside perspective when
needed. Staff also found the site visits to other states to be useful. Not only were state-level
senior managers sent to site visits, but also the regional managers who oversee the service
delivery offices. “When we saw [that] the way New Mexico does business was similar to what
Early Lessons From The Work Support Strategies Initiative: Rhode Island
13
we were talking about two years before…it takes the fear away,” one regional manager said.
“When you make changes, you’re afraid you’ll be a failure. When you see what works, it makes
it easier.”
Finally, staff saw the project’s visibility as an assist to staying on track. The planning-year
grant award to Rhode Island, albeit a relatively modest amount, gave importance to the issue of
simplifying access to work supports and helped reignite progress where the Modernization
Initiative had stalled. In the words of a sub-group participant: “When you have a high-profile
grant opportunity, it brings a level of seriousness to the effort. We were excited to create
movement on something when we were spinning our wheels before.”
Forging Common Goals among the Health Insurance Exchange, Medicaid
Expansion, and Human Services
“The biggest barriers right now are [silos]. It’s not just DHS but the whole state…Your
biggest barrier is going to be asking, ‘How do I bring it all together and bring things into
one benefit portal?’ This was the vision a few years ago and it still is going forward.”
—DHS program manager
A major problem faced by Rhode Island, and a key reason it was selected for the WSS project,
was the policy and operational division between health programs and human services programs,
compared with other states. Yet Rhode Island’s first WSS activities seemed to focus on just one
part of this divided terrain—the human services programs—and paying less attention to the
state’s medical programs, RIte Care and CHIP. That changed toward the end of the planning
year, when the WSS team plunged into the state’s broader effort to prepare for the Affordable
Care Act and health insurance exchange implementation. One WSS team member was a manager
from the Executive Office of Health and Human Services (EOHHS) and she was involved in the
initiative and in the state’s health care reform preparations. She recognized the need for DHS
also to be part of the discussions in the development of the Health Insurance Exchange and the
new eligibility system (this effort would come to be known as the United Health Infrastructure
Project, or UHIP). Engaging with these efforts proved to be one of the biggest challenges for
Rhode Island, senior DHS staff said. Moreover, the solutions will have a profound effect on the
state’s entire suite of WSS programs.
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Rhode Island is part of a consortium of New England states, led by the University of
Massachusetts Medical School, that was awarded an “Early Innovator” grant from the U.S.
Department of Health and Human Services. This grant supports states in designing and
implementing the information technology infrastructure needed to operate health insurance
exchanges. Rhode Island began to procure and implement a new eligibility system that would
accommodate health reform changes. Although this process began during the WSS planning
year, the WSS team was not initially involved.
The original plan for implementing the new eligibility system was broken up into three
phases. In phase one, the health insurance exchange would be installed and in place by October
2013. In phase two, the new system would replace InRhodes as the state’s Medicaid eligibility
system. In phase three, which had a target date of 2016, SNAP and cash assistance programs
would be added. Because the human services programs were not scheduled to be integrated until
much later, DHS staff were not included in the early planning sessions for the eligibility system.
The state was running the risk that the WSS plan, which had been primarily focused on human
services programs, UHIP’s eligibility system plan would not fit together. “While we were
crunching numbers and developing our WSS plan in this room, the health insurance exchange
and Medicaid policy people were meeting in another building and were so revved up with a
million consultants ready to meet these deadlines, but we weren’t at the table,” said a core WSS
team member.
In the last months of the planning year, Rhode Island decided to integrate the human services
programs into the new system earlier, as part of phase two. Several factors influenced this
decision. After discussions with community partners and others, senior members of the WSS
leadership team decided that a 2016 DHS integration was too far into the future. At the same
time, the national WSS team was emphasizing the importance of integrating health reform
planning with the WSS initiative, citing close linkages to health reform as a criterion for
selecting which states would move on from planning to implementation. And the federal
government’s decision to provide enhanced resources for integrated eligibility systems was
ultimately the driving factor, a senior WSS project member said. The state had to integrate all
programs into the new system sooner than originally planned or it would miss out on the newly
announced federal funding.
Early Lessons From The Work Support Strategies Initiative: Rhode Island
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Given the differing goals and timelines for the Health Insurance Exchange, the Medicaid
program, and the Department of Human Services, the process wasn’t easy for any of the groups,
but senior staffers think the result was worth it. “Literally the ground was changing,” a senior
project member said. “It was a constant challenge and a constant tension between the [two
departments] so to speak in lobbying one another.” On the other hand, the WSS team saw big
advantages to being involved earlier in the new eligibility system. It “will give us a lot of
opportunities to say what works right and what doesn’t, and if something doesn’t, let’s fix it in
the new system,” one of the state’s core WSS team members said.
As of March 2012, about two months after the change in plans, Rhode Island was an engaged
partner in completing a request for proposals for the new integrated eligibility system , including
the participating human services programs.
Engaging Frontline Workers in a Unionized Context
“I really enjoyed this because everybody was involved.”
—SNAP caseworker reflecting on the PDSA experience
During the planning year, the Rhode Island WSS team experienced successes and challenges in
engaging line workers. Many are shared by other states, but some were specific to Rhode Island
because of the state’s history and unions.
Line staff responded enthusiastically to the opportunity to help improve efficiency and
program effectiveness through local office pilots. A common theme voiced by senior Rhode
Island WSS staff was the success of business process mapping and redesign activities offered to
line workers and managers through the Southern Institute. These senior officials thought that
previous efforts to implement new policies were sometimes met with skepticism by line workers,
but the Southern Institute’s PDSA model disarmed pushback because the caseworkers
themselves were planning the new policy.
Workers agreed. A SNAP caseworker said that the PDSA process likely was the first time the
state’s eligibility technicians were invited to be a part of developing new policy and decisions
about what to change didn’t come from management. A line worker assigned to family medical
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applications also praised the process: “Everybody has a piece of this, right on back to the mail
room.”
In Rhode Island, line workers are part of a union. The WSS team met with the union to
discuss the Ford initiative and its goals before bringing the PDSA process to the workers. Some
of the eligibility technicians involved in the PDSAs were local union stewards. After
participating in the PDSA process, they expressed their support and enthusiasm for the process to
the union president and felt she was supportive in return.
However, other parts of the state’s initial strategy, particularly the idea of bringing programs
together by adopting a universal caseworker model, posed challenges. Line workers, including
eligibility technicians, are assigned to one program and generally do not check eligibility or
handle application processes across programs, DHS staff said. And while DHS administrators
and regional managers described the state’s relationship with its public employee unions as
generally positive, they felt that efforts to improve cross-program collaboration through a
universal caseworker model required ongoing discussions.
When asked what they thought about switching to a cross-program model, some line workers
articulated a willingness to change but others said they were concerned about not getting enough
training. Workers worried that each program had its own set of rules, required documents, and
steps to follow for the application process. When line workers were asked if they thought the
cross-program model would be possible with sufficient training, several staff responded that a
shift was doable but required planning to ensure no one was overburdened picking up the slack
of other workers in training.
While Rhode Island had planned to begin implementing the universal caseworker model in
the fourth quarter of the planning year, they postponed the plan to have more time for
communication with the unions. After further deliberation, senior department staff concluded a
transition to the proposed universal model may not bring the desired results. At a late point in the
planning year, senior staff said they realized that the goals of revamping business processes and
pushing for maximum cross-enrollment should be paramount and that the notion of a generic or
universal worker need not be a specific goal. Rather, the proper deployment and roles of workers
Early Lessons From The Work Support Strategies Initiative: Rhode Island
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would become evident and established as WSS-inspired reforms were studied and begun through
the involvement of all levels of the organization.
The benefits of a process approach to managing cases was advanced through the PDSAs
enacted by the department and later became a major policy goal adopted by the WSS team and
the state. Senior staff said they are confident this is an objective all levels of the department
including line staff can work toward despite necessary training and workplace adjustments.
Given the sharp reductions in staffing due to budget concerns in recent years, administrators
also thought that workers might believe cost savings, and not collaboration, was the driver for
change. A regional manager thought that workers would think that a new process management
system and talk of efficiency and cross-program collaboration was a cover to further reduce
staffing levels. The manager was also worried that workers might assume the change was
designed for management to more closely scrutinize how quickly workers processed
applications; however, line workers did not independently raise these concerns during our
discussions with them.
Using the Planning Year to Move Past Historical Barriers
“When you make changes, you’re afraid you’ll be a failure. When you see what works, it
makes following through on that change easier.”
—WSS team member
reflecting on the way the site visits helped the team move forward
The national structure of the planning year helped the Rhode Island team create a structure for
moving forward. They also thought that the fresh perspective from the technical assistance team
and the site visits to other states helped them overcome their historical challenges and an
entrenched culture.
The technical assistance offered through the WSS grant was as great, or greater, a factor of
success as the cash award itself, several senior DHS officials said. One administrator expressed
doubt that Rhode Island would have been able to accomplish its goals without the technical
assistance. “It wasn’t the funding…that was the biggest benefit of the grant; it was the assistance
and the knowledge,” one program manager said. “Folks will listen to that outside person [the
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way] you may be more apt to listen to your friend but not your parents.…When it’s brought from
inside, sometimes the culture will fight it.”
Senior DHS officials said that, before the start of WSS, they knew they had to evaluate their
business processes and become more efficient, but they weren’t sure how to move forward most
effectively until the Southern Institute helped show them the way. The state’s core WSS leaders
thought that having the Institute visit local offices and help them through the business process
mapping was crucial—and in marked contrast to previous efforts at system change. That targeted
technical assistance eventually led to the PDSAs, including SNAP same-day service. Rhode
Island also benefitted from regular webinars, consultations with experts, and learning
opportunities in other states. The concept of receiving outside help was fresh, one respondent
said, and the overall assistance bolstered the knowledge to push for change.
The site visits were a tremendous benefit as Rhode Island carried out its planning-year
activities and crafted its action plan. Visiting other states that had successfully shaken up equally
difficult service delivery problems gave them a sense of hope. Other WSS leaders said that visits
to other states fostered a better understanding of some technical aspects of policy and ingrained
Rhode Island Planning-Year Activities
Engaged outside stakeholders, ranging from state legislators to community partners and policy advocates, by
including them in WSS planning and advisory committees.
Convened three WSS-focused subgroups—business process mapping, data analysis, and policy—tasked with
identifying challenges to moving forward, proposing policy changes, and identifying components for the
state’s action plan.
Reviewed and compared eligibility and enrollment requirements with the goal of aligning the state’s suite of
WSS programs; changes not requiring legislative involvement were sketched out and implemented.
Conducted major business process assessment of the SNAP and family medical programs, with input from
frontline staff, beginning with the Providence office. One policy outgrowth on the SNAP side—a pilot to
provide same-day service to SNAP applicants—was rolled out statewide later in the planning year. A second
pilot modified how family medical applications were accepted from third-party resource centers.
Reviewed existing data and reports and developed new procedures for running reports from the department’s
data warehouse and legacy eligibility system. Also, identified shortcomings of the existing eligibility system
and explored plans for creating automated reports and a data dashboard.
Analyzed churning rates in the SNAP and child care programs.
Built close connections with the state’s health reform activities, including representing and advancing DHS
programs in the design of a new eligibility system.
Early Lessons From The Work Support Strategies Initiative: Rhode Island
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in the core team that changes on their WSS wish list could happen sooner than anticipated.
Conclusions
Rhode Island began the planning year with inefficient and frustrating enrollment processes
for work supports, less than desirable participation among eligible residents, a lawsuit over the
timeliness of food assistance benefits, and low morale among its eligibility workers and other
staff. Motivated by these challenges, Rhode Island took specific actions during the WSS
planning year aimed at improving client access to benefits, increasing cross-program integration,
and making service delivery more efficient. First, they engaged frontline workers as well as state
leaders and community stakeholders, to bring everyone on board with the WSS efforts. Second,
the Rhode Island WSS team built close connections with the state’s health reform activities,
including representing and advancing DHS programs in the design of a new eligibility system.
Third, the WSS team conducted new data analyses while reviewing existing data and reports, and
identified other opportunities for data system improvements. Finally, Rhode Island identified
opportunities to align eligibility and enrollment requirements across the state’s suite of WSS
programs, and implemented policy changes that could be made directly by the department.
At the end of the planning year, Rhode Island was awarded a three-year implementation
grant from the WSS project. Rhode Island’s action plan for the implementation stage describes
how the state proposes to make the changes they identified during the planning year. Rhode
Island’s plan includes implementation of a communications strategy targeted to underserved
populations to help them understand WSS programs for which they might be eligible, and
implementation of a staff engagement and training strategy to rekindle an agency culture that
demonstrates inherent respect for both clients and staff. The state also plans to develop a No
Wrong Door service delivery model by creating a single application for all WSS programs,
reengineering business processes, redesigning DHS lobbies, streamlining policies and procedures
across all WSS programs, and utilizing modern technology. In addition, Rhode Island’s WSS
team proposes to coordinate and integrate its activities with the states’ Health Insurance
Exchange to ensure consistency and streamlined access to WSS benefits. As part of this next
step, Rhode Island expresses its commitment to using data to guide, inform, monitor, and
continually improve program participation and service delivery. These actions are intended to
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achieve Rhode Island’s vision of increasing timely enrollment, participation, and retention of
WSS benefits while reducing administrative costs and burdens.
Early Lessons From The Work Support Strategies Initiative: Rhode Island
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References
Bureau of Labor Statistics. 2012. “Unemployment Rates for States Monthly Rankings Seasonally
Adjusted.” Washington, DC: US Department of Labor.
Cunnyngham, Karen. 2012. State Supplemental Nutrition Assistance Program Participation Rates in
2010. Washington, DC: Food and Nutrition Service, USDA.
http://www.fns.usda.gov/ora/menu/Published/snap/FILES/Participation/Reaching2010.pdf.
Kaiser Family Foundation. 2013. “State Health Facts.org: Medicaid & CHIP.”
http://www.statehealthfacts.org/comparecat.jsp?cat=4&rgn=6&rgn=1.
Kenney, Genevieve, Victoria Lynch, Michael Huntress, Jennifer Haley, and Nathaniel Anderson. 2012.
“Medicaid/CHIP Participation among Children and Parents.” Timely Analysis of Health Policy Issues.
Robert Wood Johnson Foundation. http://www.urban.org/UploadedPDF/412719-Medicaid-
CHIP-Particip.ation-Among-Children-and-Parents.pdf
U.S. Census Bureau. 2013. “Percent of Individuals for Whom Poverty Status Is Determined Below 200
Percent of Poverty in 2011. From the American Community Survey – 1-Year Estimates.”
Washington, DC: US Department of Commerce.
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Methodological Note
This report is based on several sources, including evaluation team members’ on-site and
telephone interviews with Rhode Island WSS team members and others in the state working on
WSS and related efforts; WSS materials, including quarterly progress reports and quarterly call
notes; and state documents, including the WSS proposal, action plan, presentations, relevant web
sites, WSS data exercise results, evaluation documents, and other materials. During a four-day
visit to Rhode Island in spring 2012, the evaluation team held 13 interviews with the WSS
management team, directors of local social service agencies, advocacy organizations, local social
service agency staff including union representatives, and state agency leadership and staff from
SNAP, child care, and Medicaid programs.
The goal of this Phase I evaluation was to draw on these sources to document Rhode Island’s
activities during the WSS planning year, including the challenges the state encountered and the
approaches chosen to overcome those challenges. This goal arose from the particular features of
the planning year and the nature of the lessons that could be distilled. During this phase, states
were assessing their current strengths and weaknesses and designing and testing potential next
steps, culminating in the development of an action plan (with clear goals and measurable targets
for reaching them). From an evaluation perspective, therefore, it was too early to assess whether
states had met measurable goals, but not too early to document what actually did happen, what
bumps occurred along the way, and how states responded. Thus, during the on-site visits, the
evaluation team members attempted to gather input from varied perspectives, including local
office staff and community stakeholders, but did not attempt to comprehensively gather input
from all perspectives in order to evaluate the effectiveness of planning-year activities.
Six states (Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina) are
continuing on to Phase II of the evaluation. This next phase has three major goals: to document,
understand, and draw lessons from the implementation of WSS activities in the states; to identify
and track over time key outcomes that the state would expect to be affected by its activities and
interventions; and to measure the effect WSS or specific activities under WSS had on key
outcomes. To meet these goals, the Phase II evaluation will include implementation analyses and
data tracking for all six states, and impact analyses to provide quantitative causal results where
feasible. Each state’s evaluation will be tailored to its particular activities, goals, priorities, and
data availability. The overall evaluation will combine information, analyzing data and results
from across all six states.
Early Lessons From The Work Support Strategies Initiative: Rhode Island
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