Colorado Eligibility Process Improvement Collaborative (June 2010 – September 2011)
The Colorado Department of Health Care Policy and Financing received a grant from the Colorado Health Foundation for the Colorado Eligibility Process Improvement Collaborative (CEPIC). In its grant proposal to CHF, HCPF proposed contracting with the Southern Institute on Children and Families (SICF) to work with fifteen (15) county teams to assist the counties in improving the efficiency, effectiveness and quality of processes within the public health insurance programs that support lower-income children and families, with a focus on eligibility services. The goals of the project were to: improve processing times; learn and apply new skills and knowledge; improve the quality and efficiency of internal office processes as a result of solving existing workflow problems; staff trained and proficient with a new approach to problem-solving; and staff experienced in collaborating across local offices to share successful countermeasures statewide. The CEPIC utilized small-scale plan-do-study-act (PDSA) cycles to test and adapt strategies to achieve the following example of results:
- Mesa County reported a change in processing time for Family Medicaid from an average of 36 days to less than 10 days.
- Garfield County reported a 50% reduction in processing time for Family Medicaid applications from a baseline of 20 days.
- Routt County reported a reduction of application processing time from 35 days to 7 days.
One CEPIC participant described the benefits of learning to problem-solve below:
It has made a huge difference on how we problem-solve....learning the importance and benefit of small scale testing and data gathering has been huge. Never again will I make a big change without first testing it, gathering data, and evaluating it, so I can be confident it is the right decision.
The collaborative process was hailed as great opportunity by another participant:
This collaborative was great for us, it allowed us to work through ideas we would have never come up with had we not been given the opportunity. We were able to overhaul our intake process to reduce the time to within a few days and completely get rid of our backlog. Worker and client satisfaction is amazing and cases are all being processed in a timely manner.
Medi-Cal Eligibility Process Improvement Collaborative (November 2006 – February 2008)
The California HealthCare Foundation awarded a grant to the SICF Process Improvement Center to conduct a collaborative to improve access to and retention of public health coverage for eligible families by improving the effectiveness of Medi-Cal enrollment practices in 13 California counties. The county teams focused primarily on improving work flow and customer service. By using Plan-Do-Study-Act (PDSA) cycles on a small scale, teams tested and implemented strategies. Examples of results are:
- Humboldt County estimated the impact of improvement could potentially bring $10,708,517.82 in additional state and federal revenues to county medical providers within the first year the goal is met.
- San Diego County projected that with a 27.43% reduction in discontinuances, 18,321 fewer applications will be discontinued county-wide in 2008.
The long term benefits of collaborative participation were expressed by one participant as:
“Great improvement in process. Culture change for staff to embrace change and engage in strategic planning stages. Buy in/ ownership in PDSA process alleviated fear of change. If it worked, implement it. If it didn't, tweak it or stop. Enhanced community partner communication/collaboration. Worked as one solid team. Resulted in team effort focusing on decreasing failure to provide denials/discontinuances in the Medi-Cal program. Ensuring improved outreach enrollment, retention and utilization.”
Additional information on the results of the Medi-Cal Process Improvement Collaborative can be found in the following document Slowing Medi-Cal Churn: Counties Collaborate to Improve Efficiency.
Louisiana Eligibility Process Improvement Collaborative (February 2006 – January 2007)
The Louisiana Department of Health and Hospitals engaged the SICF Process Improvement Center to improve the efficiency and effectiveness of Medicaid eligibility operations in Louisiana. This collaborative included 22 state and local teams and focused specifically on reducing application processing time. Below is a table showing processing time achieved in Louisiana:
Average Processing Time
Less than 5 days
Long Term Care
These reductions increased organizational capacity by eliminating non value added steps in the process and improved employee morale. The Louisiana Eligibility Process Improvement Collaborative ended in January 2007. Their efforts to improve continue through WorkSmart, which is their continuous eligibility process improvement initiative. The results of the Louisiana Eligibility Process Improvement Collaborative and the transformation of the eligibility process has been documented in the following document that was published by the IBM Center for the Business of Government in March 2010: Transforming State Government Services Through Process Improvement: A Case Study of Louisiana report.
Children’s Hospitals Eligibility Process Improvement Collaborative (June 2005 – July 2006)
The Robert Wood Johnson Foundation (RWJF) awarded a grant to the SICF Process Improvement Center to lead a collaborative of children’s hospitals committed to improving Medicaid/SCHIP enrollment. The collaborative included the following six hospitals from five states: Connecticut Children’s Medical Center in Hartford, Connecticut; Alfred I DuPont Hospital for Children in Wilmington, Delaware; Columbus Regional Medical Center in Columbus, Georgia; Medical College of Georgia Children’s Hospital in Augusta, Georgia; Riley Hospital for Children in Indianapolis, Indiana; and Virginia Commonwealth University Health System in Richmond, Virginia.
The original goals of the Children’s Hospitals Collaborative were to:
- Increase children’s access to health coverage when presenting for care at children’s hospitals with on-site Medicaid/SCHIP eligibility units;
- Increase the conversion of children’s status as self-pay to public insurance, thereby reducing hospital bad debt;
- Increase the eligibility processing speed and efficiency, thereby improving customer service; and
- Increase the accuracy of the eligibility process.
As a result of collaborative participation, teams achieved the following:
- Increase in patient inquiries about assistance
- Increase in the number of Medicaid applications submitted
- Increase the use of data to identify issues to address
- Increase penetration rate (Medicaid applications as a percentage of self-pay)
- Increase and improved data sharing across health system departments
- Increase communications between financial counseling and the billing unit
- Develop effective written communication with patient families about the availability of financial assistance
Team members learned that small scale testing can be used to quickly learn the potential impact of a change and to discover what is happening in a process. Following is feedback on the aspects of the learning session that were most beneficial.
“Understanding that all PDSAs do not have to be "big” things, that "fact finding missions” are as valid as a trial run of a document.”
Covering Kids & Families Process Improvement Collaborative I and II
(October 2003 – November 2005)
The Robert Wood Johnson Foundation funded the SICF Process Improvement Center to lead two collaboratives of teams composed of Covering Kids & Families grantees along with state and local eligibility offices. The goal was to maximize the efficiency and effectiveness of the enrollment and retention processes in Medicaid and SCHIP eligibility systems. These two collaboratives included 28 teams from 21 states. The second collaborative included seven teams that participated in the first CKF Collaborative and seven state teams with no collaborative experience.
The teams’ small scale testing during CKF PIC II resulted in improvements such as:
- Utilization of language indicators to match non-English speaking customers with staff who speaks their language.
- Reduction in closures due to failure to comply with procedural requirements
- Reduction in the application processing time for a hospital by nearly 50%.
- Implementation of a strategy of verification of client’s addresses at each contact
- Reduction in the percentage of returned mail by one third by using the postal service's website validation process.
Results from CKF PIC I include the following improvements:
- Implementation of the strategy of allowing clients to re-enroll by phone.
- Implementation of a standardized Medicaid application within health departments for presumptive eligibility.
- Eligibility workers complete an online application for SCHIP using Medicaid application details for applicants determined ineligible for Medicaid due to excess income rather than simply referring the family to SCHIP to make an application.
- Developed a CHIP TIPS document to obtain consistency between outreach workers regarding eligibility requirements.
- Implementation of an automated referral system between Medicaid and SCHIP that included an automated email reminder to workers to complete the referral process.
- Implementation of a simplified renewal process when a patient comes into the community health center with a need or request, the worker at the health center gets the information and calls the eligibility worker who can then renew the client over the phone.
One participant wrote about the aspects of the learning session that was most helpful:
“The environment itself is helpful. It is extremely beneficial to be reminded of and mindful of our mission/commitment to serve our beneficiaries –this is all about our customers, not us. The decisions we make about what we do, we ultimately do to our clients and workers. This so nicely frames what we are to do. I think this type of collaborative forces you to be visionary, to think about what really could be and should be better, easier, simpler, not so much about how everything has been done for years or even perhaps the havoc change will create.”
Teams found using PDSA cycles were a significant method for improving. As one participant said to be the most helpful aspect of the first learning session.
“The detailed PDSA cycles have been really helpful in hitting the ground running. In addition, we like the narrow scope of each cycle. It makes us see progress quicker and see the value in planning ahead.”
The Covering Kids and Families Process Improvement Collaboratives generated significant improvements in application and renewal processes. For further review of the impact of the collaboratives, please see: Improving Processes and Increasing Efficiency: The Case for States Participating in a Process Improvement Collaborative.
Additional retention strategies, including proven process improvement strategies, can be found in the report Covering Kids and Families: Promising practices from the nation’s single largest to insure eligible children and adults through public health coverage.
Supporting Families After Welfare Reform Breakthrough Series Collaborative
(August 2002 – February 2004)
The Robert Wood Johnson Foundation funded the SICF Process Improvement Center’s first learning collaborative as a part of the Supporting Families After Welfare Reform Initiative. Eleven county and state teams from 10 states worked to improve the efficiency and effectiveness of the Medicaid, SCHIP and Food Stamps eligibility processes. The results of this collaborative are highlighted in The Supporting Families Story: A Movement Toward Quality Improvement.
Consulting Engagements on Process Improvement
Center for Budget and Policy Priorities (April 2011 – November 2011)
The Center for Budget and Policy Priorities serves as technical assistance lead to grantee for a grant supported by the Ford Foundation and administered by the Urban Institute to institute program efficiencies, advance progress on streamlining access and enhancing the integration of services among state agencies who serve many of the same customers. The project is titled Work Support Strategies, Streamlining Access, Strengthening Families and includes nine states. The Southern Institute will work intensively on business process analysis and improvement to seven of the nine grantee states.
Louisiana Department of Health and Hospitals (February 2007 – October 2010)
WorkSmart! is the name of the continuous improvement effort initiated by the Louisiana Department of Health and Hospitals as a follow-up from the Louisiana Eligibility Process Improvement Collaborative completed in February 2007. SICF staff provided technical assistance and training to institutionalize process improvement in each parish Medicaid/CHIP office. The last deliverable for 2010 was an assessment report on the impact of telework on DHH staff and productivity of work.
Maryland Department of Health and Mental Hygiene (February – September 2008)
The AcademyHealth contracted with the Southern Institute for work for the Maryland Department of Health and Mental Hygiene. PIC staff provided two training sessions on process improvement to local health departments and local departments of social services. Additionally, the PIC provided consultation by telephone to local offices as they use PDSAs to test changes and implement improvements. Several counties were able to improve the case transfer process between the local health departments and the local department of social services.
The Lucas Group (2007 and 2008)
The Lucas Group engaged the SICF to be part of a process improvement team, as a part of its engagement with the Missouri Family Service Division which oversees eligibility policy and operations. We participated in process mapping onsite in Kansas City and provided consultation to The Lucas Group on process improvements at the state and local level.
Select Health of South Carolina (January – May 2006)
The Southern Institute on Children and Families was engaged by Select Health of South Carolina, Inc. to analyze information related to Medicaid eligibility renewal processes to identify barriers to effectiveness and make recommendations to Select Health on how to improve First Choice consumer retention.
January 2008 – March 2009
With funding from The Duke Endowment, the South Carolina Department of Social Services engaged the Southern Institute on Children and Families to implement a Child Abuse & Neglect Services Quality Improvement Project. The project focuses on DSS internal process improvement and building and strengthening community coalitions in two counties.
July 2004 – June 2006
The United States Department of Agriculture awarded a participation grant to the Southern Institute on Children and Families to increase food stamp participation in three South Carolina Department of Social Services county offices through faith-based community partnerships. The Process Improvement Center worked with the county offices to improve the eligibility process to increase capacity to accommodate a larger demand.