Use Automated Systems to Reduce Caseworker Time in Health and Human Service Agencies

Caseworker time in health and human service agencies would be reduced with automated systems, and kiosks would provide better customer service.


Background
One of the major costs in the administration of public assistance programs is the eligibility and certification process. These costs continue to rise due to increases in the number of people receiving public assistance, causing the number of eligibility ca seworkers to increase. Applications for ser vices administered by the Department of Human Services (DHS) are expected to increase between fiscal 1993 and 1994 from 168,000 per month to 190,000 per month, a 13 percent increase. For fiscal 1993, DHS will employ more than 10,453 workers in eligibility services at a cost of over $311 million. DHS has requested over 3,400 additional workers in eligibility services for fiscal 1994, a 33 percent increase over fiscal 1993. 1

Automation can help combat these higher costs. Automation is necessary to increase a caseworker s output. A good automated eligibility and certification system can reduce time per case, a caseworker s knowledge requirements and frustration, time and frustrations for clients, training time, turnover of caseworkers and sanctions due to error rates.

The federal government encourages automation of systems by providing 90 percent of the cost to develop an automated system. 2 Within the last five years, 27 states, including Texas, have had systems certified by the federal government. 3 The federal government approved Texas development plan in 1984, and in 1989, the system was operational in all DHS s Client Self-Support Services offices.

DHS developed their system in-house, including the enhancements. DHS current system includes a generic worksheet which the caseworker completes in the interview process. The caseworker completes information on different screens, such as listing the member s in the household and their ages and relationship, social security numbers, birth certificate verification, earned wages and other income. The system verifies if a client is eligible for the program the caseworker has identified.

A review of DHS system and interviews with caseworkers show the system is not user friendly. After a week of training, it takes approximately one year before the caseworker has an efficient understanding of the system. The most significant problem is that the system does not determine the programs for which an applicant and the applicant s household members are eligible. The casewo rker must determine eligibility and enter the program code into the system. Under Medicaid, an applicant or household member may be eligible for over ten programs.

Another problem with the current system is that only two types of programs can be entered for each client. For instance, if a client is applying for Aid to Families with Dependent Children (AFDC), food stamps and Medicaid, the information for one of the pr ograms must be entered as a separate case. If a caseworker chooses to determine eligibilit y for a program but additional evidence shows the client is eligible for another program, then the worker must start over. These problems were pointed out in a 1990 Deloitte & Touche study. DHS is currently developing an eligibility determination screen to add to the current generic worksheet.

Some systems designed in the private sector have proven successful in other states. California tested various systems, selecting its new system based on user friendliness and lower implementation costs. The California system used input from caseworkers which led to a system that meets caseworkers needs. The system eliminated the need for knowledge of the many eligibility rules necessary for the different programs.

This method contrasts with Texas approach in choosing a consolidated system to meet requirements of House Bill 7 (HB7), enacted in 1991. HB7 required the Health and Human Service Commission to develop an integrated eligibility system for three pilot loca tions. This system is being developed by an interagency work group; however, a system developed by a private corporation and used by the Harris County Hospital District is already available.

The Harris County Hospital District was awarded a grant from the Texas Department of Health (TDH) for $250,000 to analyze the effectiveness of using a preliminary integrated eligibility certification screening process. One of the major goals of the system is to increase the number of clients certified for Medicaid so women and children can obtain needed medical care. T he system determines Medicaid eligibility, eligibility for state and local programs such as AFDC, food stamps, the Women, Infant and Children (WIC) program and the indigent health care program for the Harris County Hospital District. The system is called T hird Party Assistance Software System, which was developed by a private corporation, and is also being used by the University of Texas Medical Branch in Galveston and Parkland Hospital in Dallas. According to an evaluation of the system performed by Harris County, a 70 percent increase in Medicaid collections occurred from 1991 to 1992.

If this system determines an applicant is eligible for a program administered by DHS, then a DHS caseworker still interviews and certifies the applicant for the program(s). Current federal regulations do not allow anyone other than a DHS employee to certif y an applicant. With the Harris County eligibility system, the DHS interview time was reduced by over 50 percent. DHS does not accept the computer-generated application com pleted by the Harris County personnel. Instead, they require the client to complete DHS form.

According to the federal Health Care Financing Administration (HCFA), there is no regulation to prevent a client s application from being computer generated if it has a signature line and a disqualification statement. 4 The Harris County worker has no access to DHS system to verify current eligibility and status of the pending application, nor does DHS accept the electronic transfer of data from the Harris County system.

In contrast, TDH contracts with health clinics for the WIC program. The health clinics determine eligibility and enter the information into the Health Department s system. The information is then transmitted to the TDH s database. Louisiana has recently contracted their Medicaid intake to third party public and private health care entities.

DHS also requires a face-to-face interview with all clients, but HCFA s policy is that a face-to-face interview with an applicant is preferred, but not req uired. In the rural areas of Texas, it can be a hardship for the client to travel to the nearest DHS location to apply for Medicaid. Most rural hospitals have the staff to interview the client and obtain the application and necessary documentation to give to DHS for certification.

Another automation tool to improve the intake and eligibility process is a touch-screen computer through which an applicant could enter data. Touch-screen computers can range from simple to elaborate kiosk systems, with video and audio capabilities. The DHS application form completed by the client has over 90 entry fields which must be entered by a DHS worker. Time would be saved in entry and in reading the applicant s handwriting if the app licant entered the information. Applicants can also read their rights and responsibilities on a kiosk. Currently, the DHS caseworker reads each applicant their rights and responsibilities. Other states use a required video.

Tulare County, California, uses kiosks in public assistance offices. Th e kiosk talks directly to the applicant and assists in completing forms. It is user friendly because it uses a touch-screen computer and is programmed for six languages. A caseworker reviews and makes corrections to information entered by the applicant. T he type of kiosk used by Tulare County costs approximately $15,000 and can handle approximately 50 cases per day depending upon the hours. 5 The Tulare County offices extend their hours to 9 p.m. to increase accessibility for clients. The system reduced err ors because the caseworkers were able to focus on the interview and to check information instead of focusing on data entry. Workload increased in both productivity and quality of work. By implementing a freeze on new workers, and through attrition of some existing workers, material savings resulted within two years of implementation.

Improvements in automation, however, will not address the problem of accurate estimates on true workload needs of health and human service agencies. The Wisconsin Department of Health and Social Services developed a workload measurement laboratory in conjunction with the more typical Random Moments Study (RMS). Although DHS and other states often conduct RMSs, the laboratory concept is different, measuring exactly the time re quired to perform various caseworker tasks and percentage of time spent in these and other tasks. The study found that many offices had more workers than they needed, and the Wisconsin Legislature reduced the request for new caseworkers by 80 percent.


Recommendations
A. The Department of Human Services (DHS) computer system needs to be enhanced to identify programs for caseworkers for which applicants are eligible. An independent analysis of the cost of the necessary enhancements to DHS system compared with purchasing or contracting outside for the enhancements should be performed prior to spending additional state funds. System designs should have caseworker input to ensure a user-friendly system.

The DHS system should have enhancements so that basic information should automatically identify all the programs for which the client is eligible. The system should also focus on the needs of an entire household. The system should also be expanded to handle multiple programs simultaneously. This should reduc e the caseworker s time in the interview process by approximately 15 minutes.

B. DHS should request a waiver from the U.S. Department of Agriculture, the U.S. Department of Health and Human Services and the Health Care Financing Administration to allow h ospital districts to determine eligibility and certification of clients. The appropriation to fund this activity should be contingent on approval of the waiver from the federal government.

The hospital districts currently staff approximately 3 percent of DHS eligibility caseworkers who basically sign off on eligibility determination by hospital district workers. Their salaries are paid with local and federal funds. By allowing hospital distr icts to certify, the state would save the indirect cost of having these employees on the payroll.

C. DHS policies should change to allow information from hospital districts to be transmitted to their system electronically. Computer generated application forms prepared by hospital districts should be accepted by DHS if they meet the agency s application information needs.

This would save approximately 30 minutes in DHS entry time. It would also assist the public assistance applicant by eliminating duplication of effort.

D. DHS should not require a face-to-face in terview for every application, but instead should waive this requirement for people applying through outstationed Medicaid workers in hospitals and for offices in rural areas where transportation causes a hardship.

E. In large offices, DHS should install touch-screen computer kiosks, which applicants could use to complete the information on the application or update information from prior applications. Prior to the purchase of kiosks, DHS should place videos in wait ing areas to inform clients of their rights and responsibilities.

A kiosk would save entry time of approximately 30 minutes by the caseworker on each case. DHS offices should use extended hours so the kiosks could receive maximum use.

F. DHS should contract for an independent laboratory and complementary time study to determine how long it takes to perform eligibility and certification tasks.

This time study should be used to determine staffing needs in each office.


Implications
The advantage of additional automation is added service to the applicant without additional staff. Further automation of eligibility determination should enhance quicker decisions, thereby providing better service to public assistance recipients.


Fiscal Impact
Additional administrative costs due to automation and studies would be offset by cost savings. The savings in processing time is estimated to be approximately $10.9 million each year. The change would reduce DHS staff by 248 employees for fiscal 1994 and another 378 employees in fiscal 1995, for a total eligibility staff reduction of 6 percent. In its appropriation request, DHS has asked for a staff increase to cover welfare applications for the 1994-95 biennium.

The cost for the studies, new system development and kiosks would be approximately $7 million over the next five years. Minimum costs occur after fiscal 1995 and would be funded approximately 50 percent by the federal government. The federal government wo uld also benefit from the savings by 50 percent.

The net estimated savings for general rev enue over the next five years would be $20 million; local governments would save $2.7 million, and the federal government would save $20 million. These savings would depend upon the rate at which the agency implements the new policy. To recognize certifiab le savings, appropriations to the agency would have to be reduced.

Gross Savings to Net Savings to Reduced Cost
Fiscal the General Revenue Administrative the General Revenue to Federal Change in
Year Fund 001 Costs Fund 001 Funds FTEs

1994 $1,804,000 $1,408,000 $ 396,000 $ 396,000 -248
1995 5,317,000 2,029,000 3,288,000 3,288,000 -626
1996 5,489,000 48,000 5,441,000 5,441,000 -643
1997 5,489,000 48,000 5,441,000 5,441,000 -643
1998 5,489,000 48,000 5,441,000 5,441,000 -643



Endnotes
1 Texas Department of Human Services, Legislative Appropriation Request FY 1994-1995 (Austin, Texas: Texas Department of Human Services), pp.160-185.
2 U.S. General Accounting Office, Welfare Programs, Ineffective Federal Oversight Permits Costly Automated System Problems (GAO/IMTEC-92-29, May 1992), p. 9.
3 Ibid., p. 33.
4 Interview with Gary Martin, Regional Office VI, Health Care Financing Administration, U.S. Department of Health & Human Services, December 4, 1992.
5 Wayne Hanson Hello and Welcome to the Tulare Touch, The National Eligibility Workers Association Directions, Vol. XVII, Winter 1992, p. 2.