AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
ADRIENNE AKERS: Good morning. Is this off again? Okay, we’ll just speak into it. My name is Adrienne Akers. I’m a senior researcher at the Early Intervention Research Institute and work with Rich Roberts. And Rich and I have worked together on a series of Integrated Services grants through the Division of Services for Children with Special Health Needs and MCH and the third of which is been called Opening Utah’s Doors. And that began back in 2001 and we’re just coming up on our fourth year and this grant is also similar to one that Arizona has had that Karen and Lee have been working on with Kathy and the families in Arizona . But the purpose of all those Integrated Services grants was to really focus on helping organize services so families could use them more easily, which again is the fifth outcome of the six that were mentioned earlier, related to building a system of care for children with special health care needs.
And we had some requirements of the grant, oops, yeah, I created that slide at the last second, I don’t think you have this one. Anyhow, there were some requirements of the grant and one the barriers that some time ago the families who were informing the Federal Interagency Coordinating Council about what the greatest barriers were for families. One of the barriers, were just all that repetitious filling out of forms over and over and over again and how frustrating that was for families and so one of the recommendations that came out of that is to develop some sort of interagency single application or eligibility process, and I cite Suzanne Braunheim for producing that document. So, in writing our grant we had letters of support from major state programs and agencies saying, yeah, we think it’s a great idea, but several naysayers that had said, you know, we’ve tried to do some sort of single application in the past and it’s never really worked.
We’ve gathered all this information but, you know, my agency needs to have it’s logo on top, or I can’t put that on my application, and the only mental model that we had as we were starting in 2001 was something that was similar to what the state of Indiana had been able to push through, which was a big, fat paper application that three or four state programs agreed to use. And so, this was where I began in my thoughts. And so, again, these were our initial partners, but what I’ll point out is, the model I’ve come to find to be more useful when you’re trying to build partnerships comes to me from my early work as a physical therapist and observing preschool teachers and how they helped children stay in a group. And what I would notice is, is if the kids were sitting in a circle, inevitably there’d be a couple of kids wandering off or goofing around and not really wanting to participate. And if they spent their time trying to drag those kids in, the ones that were actually sitting and paying attention lost interest.
On the other hand, if she made this story she was telling, or activity quite interesting, the kids, of course, in the group were interested, but pretty soon the ones that were wandering started to find their way back into the group. And so, that is just a little story to think about, where to put your energies when you’re trying to build partnerships and realize that maybe not all the partners are here right now, but trust that if you make that activity really interesting they may eventually join in. Or else you’ll decide you don’t need them anyhow. Anyhow, again, our work at the Early Intervention Research Institute is also very much focused on using a participatory action research model as Arizona pointed out and Sharon’s using in the Wisconsin group, then again, it’s really to help insure that the results are meaningful and will make a difference in the lives of the key stakeholders, particularly children and families.
And I can only second and third and fourth the motion of how critically important families have been in this whole process because when they’re the ones that are talking to the administrators or the legislators, it’s heard in a much different way. Even in some situations, talking to physicians when they haven’t been partners on the team, they hear parents much more easily than, again, other team members. So, families have been strong partners all along the way. So, here we are faced with this process of an interagency application, families are frustrated filling out all these different applications as they’re trying to get their child the services that they need, and one of the things that was a very serendipitous event is as I mentioned, we had a paper based model in mind, a fat paper application, and just after our grant was funded, Utah has a series of local interagency councils and Richard had been participating in one in the Provo area, which is a very populated, high birthrate area of Utah, and he said Adie, I think you need to come to this meeting because there is somebody down there that is going to do this presentation on some sort of computer thing in applications, and that’s about as much information as he had on it.
So I almost didn’t go to that meeting. I’m sure I would have eventually have gotten connected, but what had happened was, there were two young men that were working at a private non-profit in the Provo area that helped under-insured or uninsured families find resources in the community. And it’s almost sort of like the Emperor’s New Clothes, they recognized how frustrating it was for families to have to fill out all these applications and thought, this is really dumb. I bet we could write a little computer program and pull this together. Because they weren’t jaded by the bureaucracy they just turned to their supervisor and said do you mind if in our spare time we tinker around with this. And she’s like, yeah, sure I don’t care. And so, what they were presenting at this meeting that Richard and I attended was the prototype of this concept, which was just so simple but yet quite remarkable, and nothing that fifty year olds had thought up. It was something that that younger generation could sort of see through the mess we’ve sort of made with all this and be able to make some sense out of it.
So they idea was to simplify this through an integrated online web based methodology and this is what we’ll get to see just a little bit of. And I’ll try to go through it briefly so you at least get a flavor for it. But what the Universal Application System is, is it’s a web based interagency application process, it’s designed to help families apply for multiple programs and services online and it’s currently available in English and Spanish and the language adaptation is actually fairly simple for other languages to be added in. And again, our original goal was to help families, it wasn’t necessarily to make it easier for agencies, that’s something that is actually happening now, but we kind of kept our eyes on this very focused idea of helping families apply for multiple programs. So, I wanted to do just a quick, definitional explanation so you have a little clearer idea of what we were really trying to do. We were trying to do the first step in the process, which was to help families get the paperwork filled out, that’s the application process or the upfront information that the client provides so that the agency can then consider that and determine if their needs meet what the agency has to offer.
What we’re not trying to do is an eligibility process and that still requires the human element of an intake worker and the agency’s requirements or guidelines to be considered in order to determine that eligibility. So we’re just trying to do that first part of that process and so that’s why I wanted you to see that little difference because I know when we got the grant the idea was a common application eligibility or enrollment process and many of those things are just sort of used in a sloppy, not very consistent way. So the purpose of the universal application system is to streamline that application process, empower families, minimize the application errors and assist in overcoming language barriers. So currently, you had seen the partners that were involved that were willing to support the idea. One of the first steps was to really figure out what programs families really thought were most important to be on there, as well as, which of those partners felt like they could really participate in this process.
So here are the ones that are currently involved in the universal application system: Medicaid- Baby Your Baby is presumptive eligibility for pregnant mothers for Medicaid so they didn’t have to wait for full processing time, and Head Start, some mental health programs, and a variety of them. We let the families tell us which programs they really wanted at this point. Then the thing that again, trying to use more of a grass-roots model, we needed to pilot this at the community level because even though these young men had designed a very clean system, we needed to make sure this worked for not only the families but that the agencies at the community level had some input about how to make this process most useful. We piloted the Universal Application System for about 18 months in those three communities and when we went to the communities we actually started with their local interagency council that already had a commitment to organizing services so that we already had sort of a team in place, we didn’t have to start at the ground level.
And as we continue to roll this out across the state we’ll follow a similar process, but here’s some very simple data that was collected as part of the pilot, but 94% of the families who logged into the Universal Application System were able to finish it in one session. If you look at that next grouping of data, 52% it took less than 30 minutes and for the other 50% it took up to an hour, a few it took over an hour. And of course that would depend on how many applications they actually selected to complete and were screened for. This really surprised us, 64% of the families who did it used it from home, so the concept of having it available 24/7 is pretty amazing. Now given those three communities, Provo , because it’s in the area of Brigham-Young University , of course a lot of young families who might be students would be using the systems, they might have more availability with computers. But even in smaller, rural areas like Vernal, even still, families had a fairly high access to computers.
And what we also did, and we have brochures and I didn’t get those out, I’ll grab those in a minute during the break, but each community identified some community locations like their Work For Services offices, the library, where families could go in and use the computer if they didn’t have one, and if anybody has been into their local library lately that has a computer bank, I don’t know about you guys but they’re always packed and people know to use those computers. And here it goes to show that for 47% of the families, they only used it to fill out one application, again this is a small sample, we expect this to rise in the future with the statewide rollout. But about 15% filled out two, three, or four applications so, again, it just depended on the family's needs, what they needed.
But one of the things we did learn was, one of the reasons this was so successful was, in the Department of Health a woman named Rhoda Nicholas, who was their chief information officer, recognized the concept of what we were doing and how this was so much more useful for everybody, over and above what was currently happening in the Department of Health where several programs, Medicaid, the CHIP program, the WIC program all had federal mandates to try to get their applications online, or statewide mandates, and so there was a sort of Gold Rush mentality of all these agencies trying to be the first one to get theirs online, so they were all contracting with different software developers and what they would have ended up with was a series of parallel applications that didn’t speak to each other. And it would be not much better than a family having to input the information multiple times online rather than being actually able to do this once.
So since that pilot process happened we’ve been able to use blended funds to move from a federal grant to a statewide implementation, and last summer the Utah Department of Health and our project blended funds to go statewide and one of the things we learned in our pilot, because our mental model of developing this system was to help a family who had a child with special health needs fill out multiple applications, well what if a family had two children with special needs, what if they had another family member that fit some other program on there? Well, the way that original concept that these young men thought of was set up, it was only to enroll one person, so if you needed to enroll one person you would have to create a new account. So the new one, all family members can apply via a single account and an individualized screening that will identify their needs. New clients can enter either from the Universal Application System, which is called utahclicks.org or straight through Medicaid, straight through the Baby Watch program, and then be lead back into it.
So it would give multiple points of entry for the savvy computer user, and again, this new version is available in English and Spanish. So here’s what it looks like: Welcome to the Universal Application System, the things that we have tried to use in the website followed what these two young men originally developed, which was to keep it clean, simple and intuitive, and there weren’t a lot of, and when I use the term bureaucrat that’s not necessarily a negative term, but sometimes is has that sort of a connotation that people who work for state agencies, this wasn’t developed by a committee, it was developed by some young men who saw the process and then got input along the way to make sure they were on the right page, but it’s not real cluttered and it’s not overly wordy. And so what this little section says down here, it just says this is designed to help Utah families find programs and if you’re interested they can go on right here as a new user, and click on that, and get started with the process.
Now right down here, again, these are one line descriptions of each of those programs, so the family can look at and say, yeah, that sounds like something I’d want, nah, that’s not for me. But it’s not a big, long paragraph with every single rule and regulation or, you know, too much information for the family, and these are actually live links, where are we here, it’s not working. These are actually live links so if they want to click on that it goes right to the agency’s website and they can find more information, but we’re trying to use the internet for what it’s meant to do, is to kinda let families choose what level of information they need, or the customer. So once they get started, for instance they would go on here and click it and get started, it would lead them into adding adults to the household, and a graduate student, this is the nice Simpson family. Homer’s the father and they simply just start adding information and then birthdate and gender, and as they click add adult, what it’ll, oops, this isn’t live, now we add the mother’s name, and we keep clicking this until the adults are added and then we now enter children into the household, and so Bart is going to be added, and we add them, oops, and then we add Lisa to the system.
And now this shows that here’s the families that can be screened, and what this person has decided to do is just have the children screened, they don’t want any additional programs for the parents, not that they probably don’t need them, but it leaves it up to the consumer who wants to be screened. So if a family really just does want to look for one child and maybe they have six children, the children would be entered but they would unclick those, so again, it’s under parent control. So what ends up happening next is each person is screened, and they are screened on some very, very broad screening characteristics, their age, their income, which are added very early on in the system, whether the mother is pregnant, for instance, if the child is under three and the parent has concerns about developmental delay, that’s enough to spring a Part C application or a Children’s Special Health Care Needs application.
So they’re very, very broad and then at this point we changed the way this page looks, so this is now showing the results of the screening, and what it is showing is that Bart may or may not be eligible for certain programs, as well as Lisa, and this is one that we are going to be pilot testing. I’m still not 100% thrilled with how this looks to the consumer, but what we’ve been able to find out is that rather than, again, the state office people saying, well I don’t like the way that says that, we let the consumers tell us that through the pilot testing and what makes the most sense, and that again seems to make this move forward pretty easily. So what now happens is, is now that, depending on what programs are clicked and unclicked over here, those are the only applications that the family will be asked questions to populate, and so rather than the next part of the system being sort of filling out an application that looks like an application online, what the system now knows to do is gather all the demographic questions across those applications and group them in a logical order, then gather all the income questions, gather the employment questions, gather the health questions, and ask them in a cohesive manner rather than asking those across each of the applications. And so, at that point, what’s happening here is, I think I went, okay, these are where those questions are being asked, for instance, like the household information, and they are asked those kinds of questions, the family fills them out, and then, here’s income information, and then the final output is, congratulations, you’ve finished it.
And now, down here, you can see that they can view or print or submit electronically their application for Medicaid. And so, if they want to view and print it, there’s Utah ’s Medicaid application populated with the family’s information, here’s the early intervention application populated with the family’s information, and so on. And so that’s where the beauty of their concept was because there are several states that do, Arizona self help screening wizard where families can go in and find a number of applications or programs they may be eligible for but they haven’t been able to take that next step yet which actually populates the forms. It just says, yea, it looks like you might be eligible for that, they may even have some applications to download, but it doesn’t actually input the family’s information on the application, so that’s why this concept is really just something that the time has come.
Well, and the other thing it does do, there’s the Head Start application filled out, and it also give some information, you know, to submit your WIC application here’s the address of your local office, it’ll tell them you need to call and make an appointment, or you need to bring in your verification of your social security number, those sorts of things the agency will actual need in order to move the process ahead. But the one thing that I think has been a real useful concept is that we’re not trying to do everything, we’re just trying to make the process simpler. So for instance, we’ve even had a story where one of the parents in one of the rural communities came up to me and said, can you tell me just how secure this system is? And I said, well what they tell me is, is that it’s, because I don’t have an information technology background or training, I just learn along the way, that it is as secure as online banking. And she said, well my husband and I aren’t even comfortable doing that.
So I said, well you know, this will be for designed for families who are comfortable for doing this online. If you aren’t, you can still fill out the paper application and she said, oh, okay. So she sat down, she came back up after the break and she said, you know, I wonder if you could do it this way? Like for instance, if there was information a family was uncomfortable putting online, like my husband and I wouldn’t put our social security number online, could they leave that blank and then they could still submit the application. Well we’d never thought of that because all we could think of is when you’re ordering from Lands End and you don’t stick in the right piece of information, you know, you get an error message, and so what we decided to do is allow for, of course they would have to input their name and they would have to put in some basic information, but as much as possible, if families choose not to want to provide that information online, they still have to go into the office, they still have to have a phone conversation, where that information can be gathered in a way that doesn’t feel as intrusive to them.
And so, again, just that whole idea of having partnerships where people are willing to listen to one another and what’s really important in order to make a process go ahead is really important. So to make a long story short, this is just an, I won’t go over this but in this newest version, we realized when we did the piloting that we couldn’t ask the local agencies to manage electronically pushed applications because they were just smaller community offices, they didn’t have a mandate to accomplish all this electronically and we didn’t have the funding, literally, to be able to insure that they were set up to be able to handle them online. So based on the pilot, the state asked us to partner with them, they blended funds with us and supported the development of an eligibility staging area whereby now it’s set up so that as the family hits submit those applications are sent to, based on Zip Code, to a website, where their local office can on a daily basis pull up any new applications that have come in, assign them to intake workers and process them online and communicate with the families.
So that’s kind of the newest piece of this and I’m going to try and stop right here because I think we’ve all been sitting along time, but Oregon is now about to enter into a contract with us to help bring that up, Arizona’s been very interested, Katherine has been making recommendations to the governor as part of a task force and then I had somebody from their Department of Economic Security call me, who didn’t know Katherine, saying we heard about your system, we want to do it. So I had the fun of being able to link those two Arizona people together on this same process. And so there are several other states that we are beginning these negotiations with, so it’s pretty exciting, and I’m sure everybody will have questions for all of us at some point and maybe we’ll do that after the break, I’m not sure. Yeah, okay. Does anybody have any quick questions about that? Thanks.