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Five things to keep in mind during your CCWIS transition

09.10.18

Modernization means different things to different people—especially in the context of state government. For some, it is the cause of a messy chain reaction that ends (at best) in frustration and inefficiency. For others, it is the beneficial effect of a thoughtful and well-planned series of steps. The difference lies in the approach to transition - and states will soon discover this as they begin using the new Comprehensive Child Welfare Information System (CCWIS), a case management information system that helps them provide citizens with customized child welfare services.

The benefits of CCWIS are numerous and impressive, raising the bar for child welfare and providing opportunities to advance through innovative technology that promotes interoperability, flexibility, improved management, mobility, and integration. However, taking advantage of these benefits will also present challenges. Gone are the days of the cookie-cutter, “one-size-fits-all” approach. Here are five facts to consider as you transition toward an effective modernization.

  1. There are advantages and challenges to buying a system versus building a system internally. CCWIS transition may involve either purchasing a complete commercial off-the-shelf (COTS) product that suits the state, or constructing a new system internally with the implementation of a few purchased modules. To decide which option is best, first assess your current systems and staff needs. Specifically, consider executing a cost-benefit analysis of options, taking into account internal resource capabilities, feasibility, flexibility, and time. This analysis will provide valuable data that help you assess the current environment and identify functional gaps. Equipped with this information, you should be ready to decide whether to invest in a COTS product, or an internally-built system that supports the state’s vision and complies with new CCWIS regulations.
     
  2. Employ a modular approach to upgrading current systems or building new systems. The Children’s Bureau—an office of the Administration for Children & Families within the U.S. Department of Health and Human Services—defines “modularity” as the breaking down of complex functions into separate, manageable, and independent components. Using this modular approach, CCWIS will feature components that function independently, simplifying future upgrades or procurements because they can be completed on singular modules rather than the entire system. Modular systems create flexibility, and enable you to break down complex functions such as “Assessment and Intake,” “Case Management,” and “Claims and Payment” into modules during CCWIS transition. This facilitates the development of a sustainable system that is customized to the unique needs of your state, and easily allows for future augmentation.
     
  3. Use Organizational Change Management (OCM) techniques to mitigate stakeholder resistance to change. People are notoriously resistant to change. This is especially true during a disruptive project that impacts day-to-day operations—such as building a new or transitional CCWIS system. Having a comprehensive OCM plan in place before your CCWIS implementation can help ensure that you assign an effective project sponsor, develop thorough project communications, and enact strong training methods. A clear OCM strategy should help mitigate employee resistance to change and can also support your organization in reaching CCWIS goals, due to early buy-in from stakeholders who are key to the project’s success.
     
  4. Data governance policies can help ensure you standardize mandatory data sharing. For example, the Children’s Bureau notes that a Title IV-E agency with a CCWIS must support collaboration, interoperability, and data sharing by exchanging data with Child Support Systems?Title IV-D, Child Abuse/Neglect Systems, Medicaid Management Information Systems (MMIS), and many others as described by the Children’s Bureau.

    Security is a concern due to the large amount of data sharing involved with CCWIS systems. Specifically, if a Title IV-E agency with a CCWIS does not implement foundational data security measures across all jurisdictions, data could become vulnerable, rendering the system non-compliant. However, a data governance framework with standardized policies in place can protect data and surrounding processes.
     
  5. Continuously refer to federal regulations and resources. With the change of systems comes changes in federal regulations. Fortunately, the Children’s Bureau provides guidance and toolkits to assist you in the planning, development, and implementation of CCWIS. Particularly useful documents include the “Child Welfare Policy Manual,” “Data Sharing for Courts and Child Welfare Agencies Toolkit,” and the “CCWIS Final Rule”. A comprehensive list of federal regulations and resources is located on the Children’s Bureau website.

    Additionally, the Children’s Bureau will assign an analyst to each state who can provide direction and counsel during the CCWIS transition. Continual use of these resources will help you reduce confusion, avoid obstacles, and ultimately achieve an efficient modernization program.

Modernization doesn’t have to be messy. Learn more about how OCM and data governance can benefit your agency or organization.

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Consulting

Organizational and Governance

The Merriam-Webster Dictionary defines leadership as having the capacity to lead. Though modest in theory, the concept of leadership permeates all industries and is a building block for every organization’s success. Too often, however, organizations fail to invest in leadership training.

This is especially true of government healthcare agencies that often fill managerial roles by internal promotion based on skill sets and experience, rather than leadership ability. Largely due to the nature of the healthcare industry where technical aptitude is valued highly, this is not surprising. Often the leaders with the capability to engage employees, encourage quality performance, and drive change are not promoted. Because these leadership qualities are essential to organizational transformation, providing comprehensive leadership training to both clinical and administrative staff is crucial for organizational success in the healthcare field. This is where business analysis can help.

Business analysis, or the practice of enabling change in an organization by defining needs and recommending solutions, can help customize training programs for your organization’s current needs and future goals. Here are a few ways elements of business analysis can be used to analyze your organization for leadership development needs:

  1. Elicitation and Collaboration: the process of obtaining and reviewing information from stakeholders and other sources. This step confirms the need for leadership training as a project requirement, and provides insight into specific areas where supervisors lack proficiency. Though the process is ongoing, it is especially important to confirm specific training needs at the onset of a project.

    Methods such as document analysis, mind mapping, focus groups, surveys, and observation help properly elicit information from stakeholders. Gathering important information at the project start can help you create a tailored leadership training approach. For example, if separate competency deficiencies are discovered between clinical and administrative staff, variations of the training program can be implemented to fit organizational need. 
  1. Requirements Life Cycle Management: the supervision of the strategy, from project inception to completion. This ongoing process traces the relationships between the training program and all other elements of the organizational transformation. Through techniques such as process and scope modeling, it provides ongoing improvement of training throughout the project’s life cycle. Additionally, it confirms with stakeholders that the training is on track.
     
  2. Strategy Analysis: the study of how a leadership development program will enhance your organization’s existing needs and future goals. Analyzing current and future environments can reveal how to integrate the leadership training program into your organization’s strategic plan. This process helps uncover any associated risks, which then drive your change management strategy. This ensures smooth incorporation of the training program, using techniques such as business capability analysis, prototyping, and root-cause analysis.
     
  3. Requirements Analysis and Design Definition: the creation of a leadership training strategy. Known in the industry as RADD, this multi-tiered process focuses on determining strategy. It includes:
  • Verifying specific requirements the program should meet
  • Ensuring all requirements collectively support one another
  • Creating and comparing multiple leadership training options

Once RADD is complete, you can determine the best option and move forward with a personalized leadership training program for your organization. Approaches that can help with this complex process include (but are not limited to): risk analysis, surveys, organizational modeling, workshops, and assessment of Key Performance Indicators (KPIs).

  1. Solution Evaluation: the method used to assess overall performance and value in order to optimize the leadership training program. This process involves measuring and analyzing current performance indicators, identifying barriers, and recommending plans of action to enhance the program, if necessary. It’s important to get feedback from staff and stakeholders during this process to define various strengths and gaps in the current program.

These business analysis elements can work together to develop leadership capacity during organizational transformation, resulting in supervisors who can engage employees, encourage quality performance, and drive change. Especially in the health sector, where the regulations are heavy and the stakes are high, having supervisors with this capacity is immensely important. Inspired leaders can truly transform an organization, as inspired leaders drive inspired organizations.

Once you implement a customized approach, not only will “leadership” go from a buzzword to a valued organization standard, but trained leaders will become the central support system as you move into the future and continue to provide for the health of your customers.

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Transforming your government healthcare agency through leadership training: A business analysis approach

Read this if your organization offers health insurance through a health insurance exchange.

When the Affordable Care Act (ACA) was passed in 2010, it contained a known gap which made healthcare premiums unaffordable for some families covered under Medicare or employer-sponsored health insurance plans. The gap in the law, commonly referred to as the family glitch, was formalized in 2013 as the result of a Final Rule issued by the IRS. 

The “family glitch” calculates the affordability of an employer-sponsored health insurance plan based on the cost for the employee, not additional family members. An article published in April 2022 on healthinsurance.org estimated that the cost of health insurance for a family covered by an employer-sponsored plan could end up being 25% or more of the household’s income, even if the plan was considered affordable (less than 9.61% of the household’s income) for the employee alone. Almost half of the people impacted by the family glitch are children.

The family glitch was allowed to stand in 2013 partly because of concerns that resolving the issue could push more people off employer-sponsored plans and onto marketplace qualified health plans, ultimately raising the cost of subsidies. Since then, several attempts have been made to fix the issue, which affects around five million Americans. The most recent attempt was an executive order issued by President Biden soon after taking office in January 2021. The Office of Management and Budget has been reviewing regulatory changes proposed by the Treasury Department and IRS, details of which were published in April 2022. 

These regulatory changes would alter the way health insurance exchanges calculate a family’s eligibility for subsidies when the family has access to an employer-sponsored health insurance plan. If the changes go into effect in 2023 as proposed, audits of the 2023 fiscal year will need to account for the new regulations and potentially conduct different testing protocols for different parts of the year. 

Our team is closely following these proposed changes to help ensure our clients are prepared to follow the new regulations. Earlier this week, we attended a public hearing held by the Treasury Department, where representatives of various groups spoke in support of, or in opposition to the proposed regulatory change. Supporters noted that families with plans that offer expensive coverage for dependents would benefit from this change through reduced costs and more coverage options, including provider networks that may more closely align with the family members’ needs. Those in favor of the change anticipate that families with children would see the most benefit. 

Those opposed to the change expressed that due to the way the law is currently written, they do not see the regulatory flexibility for the administration to make this change through administrative action. Additionally, concerns were raised that families covered by multiple health insurance plans could be faced with higher out-of-pocket-costs due to having separate deductibles that must be met on an annual basis. Lastly, not all families that have unaffordable insurance would see financial relief under this proposal. 

The Treasury Department is expected to announce its decision in time for open enrollment for plan year 2023 which is scheduled to begin on November 1, 2022. Our team will continue to monitor the situation closely and provide updates on how the changes may impact our clients. 

For more information

If you have more questions or have a specific question about your situation, please reach out to us. There is more information to consider when evaluating the effects these changes will have on the landscape of healthcare access and affordability, and we’re here to help.

Article
Fixing the "family glitch": How a proposed change to the ACA will affect healthcare subsidies 

Read this if you have a cybersecurity program.

This week President Joe Biden warned Americans about intelligence that indicated Russia may be preparing to conduct cyberattacks on our private sector businesses and infrastructure as retaliation for sanctions applied to the Russian government (and the oligarchs) as punishment for the invasion of Ukraine. Though there is no specific threat at this time, President Biden’s warning has been an ongoing message since the invasion began. There is no need to panic, but this is a great time to re-visit your current security controls. Focusing on basic IT controls goes can make a big difference in the event of an attack, as hackers tend to go after the easy, low hanging fruit. 

  1. Access controls
    Review and understand how all access to your networks is obtained by on-site employees, remote employees, and vendors and guests. Make sure that users are maintaining strong passwords and that no user is connecting remotely to any of your systems without some form of multi-factor authentication (MFA). MFA can come in the form of a token (in hand or built-in) or as one of those numerical codes you have delivered to your phone or email. Poor access controls are simply the difference between leaving your house unlocked versus locked when you leave to go somewhere. 
  2. Patching
    One of the most common audit findings we have to date and one of the biggest reasons behind successful attacks is related to unpatched systems. Software patches are issued by software providers to address vulnerabilities in systems that act as an unlocked door to a hacker, and allow hackers to leverage the vulnerability as a way to get into your systems. Ensuring your organization has a robust patch management program in place and that systems are up-to-date on needed patches is critical to your security operations. Think of an unpatched system like a car with a broken window—sure the door is locked, but any thief can reach through the broken window and unlock the car. 
  3. Logging 
    Account activity, network traffic, system changes—these are all things that can be easily logged and with the right tools, configured to alert you to suspicious activity. Logging that is done correctly can alert management to suspicious activity occurring on your network and notifies your security team to investigate the issue. Consider logging and alerting like your home’s security camera. It may alert you to the activity outside, but someone still needs to review the footage and react to it to mitigate the threat.  
  4. Test backups and more
    Making sure that your systems are successful backed up and kept separate from your production systems is a control we are all familiar with. Organizations should do more than just make sure their backups are performed nightly and maintained, but need to make sure that those data backups can be restored back to a useable state on a regular basis. More so than backups, we also often hear in the work we do that our client’s test only parts of their disaster recovery and failover plans—but have never tested a full-scale fail-over to their backup systems to determine if the failover would be successful in the event of an event or disaster. Organizations shouldn’t be scared to do a full-scale failover test, because when the time comes, you may not have the option to do a partial failover and just hope that it occurs successfully. Not testing your backups is like not test driving a car before you buy it. Sure it looks nice in the lot, but does it actually run? 
  5. Incident Management Plan 
    We often review Incident Management Plans as part of the work we do, and often note that the plans are outdated and contain incorrect information. This is an ideal time to make sure your plans are current and reflect changes that may have occurred, like your increasingly remote work force, or that systems have changed. An outdated Incident Management Plan is like being sick and trying to call your doctor for help only to find out your doctor has retired. 
  6. Training—phishing attacks
    Hackers’ most common approach to gain access to systems and deploy crippling ransomware attacks is through phishing campaigns via email. Phishing campaigns trick a user into either providing the hacker with credentials to log into systems or to download malware that could turn into ransomware through what appears to be legitimate business correspondence. Training end-users on what to look for in verifying an email’s authenticity is critical and should be seen as an opportunity that benefits the entire organization. Testing users is also critical so management understands the current risk and what is needed for additional training. Security teams should also have other supporting controls to help prevent phishing emails and detection tools in place in case a user does fall for an email. Not training your employees on security is like not coaching your little league team on how to play baseball and then being surprised you didn’t win the game because no one knew what to do. 

In the current environment, information security is an asset to any organization and needs to be supported so that you can protect your organization from cyberattacks of all kinds. While we can never guarantee that having controls in place will prevent an attack from occurring, they make it a lot more challenging for the hacker. One more analogy, and then I’m done, I promise. Basic IT controls are like speedbumps in a neighborhood. While they keep most people from speeding (and if you hit them too fast they do a number on your car), you can still get over them with enough motivation. 

If you have questions about your cybersecurity controls, or would like more information, please contact our IT security experts. We’re here to help.

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Cyberattack preparation: A basics refresher

Read this if you are interested in grant compliance in healthcare. 

This is a companion article to the podcast, Mitigating the compliance and revenue integrity risk of grant funded healthcare programs.

The BerryDunn Healthcare Practice Group boasts professionals who have expertise all across the spectrum of healthcare, including regulatory, revenue, integrity, general compliance, and risk management issues. This article covers the very specific arena of grant compliance affecting many of BerryDunn’s healthcare, not-for-profit, and government clients.

After starting as a newly minted MBA financial analyst with an academic medical center in Northern New England, I (Markes) worked my way into the world of grants and contracts supported by my interest in federal regulations and the non-clinical revenue streams. Fascinated to navigate through waters where it seemed no one was the expert, or really had the time or patience to figure things out, I worked to stand up a grant office in finance on the hospital side, separate from the medical school which was the usual repository for grant funding. We moved this direction because hospital leadership realized grant funding was tipping toward the clinical setting and was less focused on bench or clinical research. Put another way, less NIH and more CDC, HRSA, and CMS.

BerryDunn Senior Manager Regina Alexander advises, “wherever there is complexity, there is compliance risk.” Whether from a federal agency like HHS, HRSA, NIH, or CDC, a state Medicaid program, foundation, or private source, grants always come with requirements, typically very specific requirements. Because the dollars are being ‘given’, those requirements for how the funds are used may be much more restrictive than loans.

Like other areas of regulatory compliance, it is reasonable to assume that grant programs often have compliance gaps that go unnoticed. For many of our clients, both in healthcare and not-for-profit, and in the government space, grant revenue has become a significant source of funding. Any kind of healthcare delivery organization, including academic medical centers, federally qualified health centers, community hospitals, behavioral health service organizations, home health providers, visiting nurse associations, and others can end up with significant portions of their income for the year being sourced by federal grants.

Grant compliance categories

We all can’t be experts in every domain of regulatory compliance, and grant compliance has a lot of breadth. Thankfully, at BerryDunn, we have a team of grant experts who work collaboratively across practice groups. When I was working on setting up the grant office and establishing a proprietary clinical FTE reporting process and system earlier in my career, I would have greatly benefited from the perspectives of other experts at the table.

When we think about grant compliance, four categories are helpful to keep in mind:

  1. Restricted funding
  2. Single audit
  3. Indirect rate
  4. Time and effort

Restricted funding

Firstly, and most universally understood and applied is that grant monies are, pretty much by definition, restricted. Aside from very specific and rare instances of monies being granted to beneficiaries who have no responsibility, all grant funding is awarded with the expectation that the funds will be expended in a specific way. 

Any funder, from the federal government to your local community organization like the Lions Club or the VFW, will likely require individuals and entities awarded a grant must promise to use the funds only for the purpose laid out in the award and proposal. Compliance with grant terms typically includes following the requested reporting requirements of that funder as well. Though this category may sound obvious, it's actually pretty far-reaching, as it usually affects sub-recipients (those entities who are partnered with the direct recipient to accomplish the grant purpose). For example, where the money goes after the initial awardee receives it, or rules about who can do the work, what type of organization, how you choose a vendor, etc.—all sorts of categories.

It should be noted that many of these grant award requirements are not dissimilar from work we already do in the healthcare compliance space to assist our clients in avoiding anti-kickback statutes and Stark risks. This is because grant compliance is grounded in the same basic concepts—no favoritism, no bribes or shady deals, and avoiding fraud, waste, and abuse. Especially if you're spending federal monies, you need to prove that you choose the vendor based on verifiable best practices, and consideration was afforded to organizations owned by women, veterans, and minorities.

Single audit 

The second category, Single Audit, is applicable to all federal funding of $750,000 or more annually. My colleague from BerryDunn’s Not-for-Profit practice group, Katie Balukas, explains: 

"The federal Single Audit Act is a requirement for entities to undergo an independent financial and compliance audit when the entity has expended over $750,000 in federal awards. These audits are conducted following guidance issued through the Governmental Auditing Standards and the United States Office of Management and Budgets' Uniform Guidance. The main focus of the compliance audit is to assess the entity's compliance with the requirements set forth by the federal agency that administered the grant funds. That includes, but is not limited to determining if the funds were utilized for allowable costs and activities and expanded within the proper grant period and that the reporting and performance objectives were met."

It is important to note that adequate, appropriately scaled internal resources are essential for any organization receiving grants and even more so with larger grants. Though the phrase has been overused, it really does “take a village”. Grant management isn't something an organization should do on the side, assigning grant accounting to someone who already has a full-time role, but unfortunately this is common and also unfortunate because under resourcing tends to lead to compliance concerns, as well as just plain old poor funding management. 

Indirect rate

Speaking of funding, the third type of grant compliance is very focused on a component of the grant world that really has a life of its own: The indirect rate. Though there is an accounting definition of ‘indirect’, the way it is defined regarding grant funding is pretty specific, and there is an entire body of work organizations undertake to get a federally approved indirect rate.

There's an awful lot to think about with the indirect rate. On the one hand, you could say it's pretty simple. For example, a lot of foundation funders and even some federal funders will offer you a 5% or 10% indirect rate without any need to make a calculation. That's because they know that if you take time to do the math, you'll come up with a number much higher than 5% or 10%. When it comes to federal grants and healthcare services organizations, the indirect rate is dependent on how an organization measures costs. For hospitals, of course, the method of measurement is driven by the Medicare cost report, and that's where we would do the fancy math to derive the indirect rate. But the reality is far from simple or straightforward. 

Time and effort

The fourth and final area of grant compliance, time and effort, is also the one I'm actually most passionate about and is probably the most minimized, or at the very least, misapplied. 

In one way, “time & effort” is exactly what it sounds like. Much of granted dollars, especially from the federal government, get appropriately spent on program staff. The challenge is to match time and effort to those dollars, but that isn't as clear as it sounds, because the standard way of measuring staff time is usually in a payroll system of some sort, which can't prove how time was spent.

Most payroll systems can be programmed to account for FTE (full-time equivalent) allocations; however, there is often a breakdown between theory and practice. Putting allocations into payroll, usually done without employee interaction, may show how an employee “should” spend their time, but it is really no guarantee that that's actually how they're spending their time.

So how does the organization typically go about assuring that? Now, I don't want to speak for everyone, but let's just say I happen to know that there's a place for two or three (or maybe 10,000) that basically put allocations into payroll, and then, unfortunately, often well after the fact and/or more than once, send that allocation to the employee to sign off on without really any option to disagree, or even to modify. We all know that is not compliant…but in the organization's defense, there really haven't been very good alternatives to that kind of woeful and frustrating process, at least none that have been widely shared or understood.

As often is the case in the compliance world, rules are not followed because there is no perceived risk, but that is not a winning strategy.

Though many people involved in grant management do not have any experience or even knowledge of time and effort violations meeting with any consequences, organization interest and grant compliance have more implications than just preventing front page news. What I find in the conversations with organizations, both large and small, is that loose time and effort management costs the organization in two major ways. 

Firstly, it is inefficient to scramble around at the close of each federal grant to fix time and effort allocations. The extra time spent by grant staff, project coordinators, managers, and the finance team to sort things out because they didn't get them right the first time is the worst kind of inefficient—poor use of time with an equally poor outcome. 

Secondly, loose time and effort is costly in direct salary dollars. Most grant staff are not dedicated to one project, so we need to consider the value of their other work. Whether that is on other grants or, for example, seeing patients in the clinic as many principal investigators in healthcare do, having inaccurate or fluctuating understandings of their ability costs the organization directly in wasted salary dollars or indirectly as the opportunity cost of those providers (or other roles in other organizations). 

Digging in and fixing these issues is the work I really enjoy. It's relatively simple to build a compliant model, whether that requires very little payroll redo and is just a simple recurring attestation process in built in Excel, or more complex integrated models with triggered attestations in PDF format in a database that manages the overall FTE of principal investigators. It might even drive the available clinical provider time. It can all be done. We just need to know what the goal is. 

Working in this space so rewarding, because like so much of compliance, it's about doing something better—not just being compliant—but setting organizations up to better meet their goals and fulfill their mission.

The compliance or accounting professional might still ask, “But why aren’t payroll allocations sufficient for meeting Uniform Guidance?” The truth is, when UG came into effect and superseded the A-110, 122, 133, and others, the bar was effectively lowered. Historically, organizations abiding by the old OMB circulars had to make an attestation at least twice a year, which doesn’t really seem helpful, as who can accurately allocate their time from 5 or 6 months ago? So UG did away with the timeframe reference, relying on the idea that the payroll allocations and distributions would be all that would be needed, and in the absence of those, a monthly ‘look back’ by professional staff would be in order.

I say all this, because as a result, the interpretation of ‘payroll allocations’ then becomes the standard and we have forgotten about the other elements spoken of in the regulation. Remember, for anyone salaried (the vast majority of physicians and most of the higher level grant personnel), the ‘payroll allocation’ doesn’t pass muster. It is a static allocation that has no mooring in actual activity. This is why UG calls for monthly “current and reasonable estimates” of time and effort.

So what can organizations do in response? They need to seek a solution, a process, and a method that will both pass audit muster, as well as help the organization properly manage their resources. Almost every organization manages their productivity and finances on a regular basis: monthly! That’s why the same standard should apply to grant time and effort management. It's much more reasonable to ask you how you spent your effort this month, asking you to make a reasonable estimate of your time allocations to the different efforts you worked on.

So to summarize, the four key areas of grant compliance are (1) grants are restricted funding, (2) single audit requirement for federal funding over $750,000 annually, (3) the indirect rate and related agreement, and (4) time and effort.

Of course, I would be remiss to not point out that undergirding all this is the organization’s approach to policy. Any organization that considers grant funding a regular piece of their annual income needs to have dedicated grant management policies, covering all of the above topics, with particular focus on those arenas that are unique to the world of federal funding, and being mindful to follow or otherwise update for changes in processes and/or regulations.

Final takeaways: 

  • First, what grant focused infrastructure do you have in place? If you are subject to a single audit, there should be dedicated administrative grant staff. And I don’t mean the programmatic people actually working on the grant, but people outside the grant funding—also why you have an indirect rate. 
  • Second, how are you handling time and effort? If the process relies on any long after-the-fact attestations or payroll-generated reporting, it is unlikely to be truly following the spirit…or the letter…of Uniform Guidance. 
  • Third, review your policies regarding grants. You may not actually have policies focused on grant activities, leaving them under ‘general finance’. That isn’t sufficient to cover federal funding requirements. Many have grant policies in place, but are they actually being followed through the lifecycle of your grant programs? 
  • Lastly, the grant world is a whole ball game unto itself. BerryDunn has some great resources internally to offer assistance in all phases of grant management and administration. 
Article
Mitigating risk of grant funded healthcare programs

Read this if you are at a public health agency.

As public health workforce challenges worsen through retirements, burnout, and added need for public health workers highlighted by the COVID-19 pandemic, funding levels for public health remain increased for the time being. This provides opportunities for states to leverage federal programs and funding streams to help ensure a strong and capable public health workforce to meet the needs of all communities. An important consideration for states is the level of cultural competence among their public health workforce.

Cultural competence: Definition and benefits

Cultural competence refers to the capacity to function effectively, both as an individual and an organization, in relation to community members’ cultural beliefs, behaviors, and needs. It allows public health professionals to provide more effective public health services to individuals and communities with cultures different from their own—through awareness, respect, and willingness to learn about cultural differences. The necessity of cultural competence in public health is especially timely due to new and existing disparities that have been highlighted by COVID-19 outcomes and the ripple effects of the pandemic.

Benefits of a culturally competent public health workforce include greater public trust in the public health system, more equitable and effective public health services, improved understanding of existing barriers and community health status, and the potential to reduce disparities and improve both healthcare access and health outcomes in historically marginalized communities.

As many states face significant workforce gaps and challenges in recruiting, training, and retaining staff, it is important to leverage best practices and key indicators of success to inform a sustainable and effective approach for workforce development. States may benefit from assessing gaps in cultural competence and related skills, and by identifying specific cultural competency areas and abilities they aim to achieve in the workforce. A strategic approach is necessary for maximizing the sustainability and long-term benefit of federal funding opportunities, such as those for public health workforce development in rural areas. 

Strategies and best practices for developing a culturally competent public health workforce 

There are many steps you can take toward building cultural competence in your agency. Some of them include:

  • Develop and implement a periodic assessment of workforce cultural competence, and training to measure improvement and incorporate up-to-date best practices
  • Recruit diverse staff to reflect the culture and demographics of communities, including the provision of linguistic support
  • Create and improve pipeline training programs by collaborating with local colleges, universities, and schools of public health and identifying existing gaps in the workforce and in public health educational opportunities 
  • Support inter-professional education and teams for community-based interventions, to foster collaboration between public health and healthcare professionals in the community to better meet needs 

Important first steps to improve and foster cultural competence in the public health workforce include setting goals related to building community partnerships and what those partnerships will achieve. 

Other steps for building cultural competence 

Additionally, collecting diversity data and demographic characteristics of the public health workforce, measuring and evaluating performance of the public health workforce and public health services, and reflecting community diversity within the workforce are necessary for developing a workforce that supports community cohesion and trust of community members. These steps can help you assess where you can strengthen services and how communities can be better reflected in the public health services they receive. Effective communication and language access are also critical steps to improve and foster cultural competence in the public health workforce.

BerryDunn can provide state public health and human services agencies with strategic policy and programmatic guidance and management support to maximize the benefits of federal programs to facilitate public health workforce development. 

If you have any questions about your specific situation, or would like more information, please contact our Public Health Consulting team. We’re here to help.

Article
Developing a culturally competent public health workforce

Is your Women, Infants, and Children (WIC) agency struggling with Maintenance and Enhancement (M&E) vendor management? Here are some approaches to help improve your situation: 

  • Product Management Office (PdMO): Product management can help you manage your WIC system by coordinating and planning releases with the M&E vendor, prioritizing enhancements, reviewing workflows, and providing overall vendor management.
  • Project Management Office (PMO): Project management can help with budgeting, resource management, risk management, and organization. 
  • A blend of product and project management is a great partnership that can relieve some of the responsibilities of WIC agency staff and allows a third party to provide support in all areas of product and project management.

Whether you are an independent WIC State Agency (SA) or a multi-state consortium (MSC), having a PMO and/or PdMO can help alleviate some of the challenges facing WIC today. While an MSC may present significant cost savings, managing an M&E contract for multiple states can be overwhelming. Independent state agencies (SAs) may not have multiple states to coordinate with, but having the staff resources for vendor facilitation and implementing federal changes can be challenging. A PMO/PdMO can aid in improving business and technology outcomes for SAs and MSCs by bringing a level of coordination and consistency that otherwise might not happen. 

As federal changes grow in complexity, evidenced by the many changes to WIC stemming from the American Rescue Plan Act, coupled with workforce challenges in government, the importance of a PMO/PdMO has never been greater. Here are six ways a PMO/PdMO can help you:

  1. Facilitate the vendor relationship
    A PMO/PdMO not only holds the vendor accountable but also takes some of the workload off the SA by facilitating meetings, providing meeting notes, and tracking action items and decisions.
  2. Manage centrally located data
    A PMO/PdMO keeps all documents and data in a centralized location, fostering a collaborative environment and ease of access to needed information. A centralized location of data allows SAs to be on the same page for consistency, quality control, and to support the state’s need for clean, reliable information that is current and accurate.
  3. Track and mitigate risks 
    Effective risk management requires a substantial commitment of time and resources. The PMO/PdMO identifies, tracks, and assesses the severity of risks and suggests approaches to manage those risks. Some PMO/PdMOs assess all risks based on a severity index to help clients determine which risks need immediate action and which need monitoring.
  4.  Assist in the creation of Implementation Advanced Planning Document Updates (IAPDUs) 
    Creating and implementing an IAPDU can be time-consuming, confusing, and requires attention to detail. A PMO/PdMO alleviates time and pressure on SAs by helping to ensure that an IAPDU or funding request clearly outlines a plan of action to accomplish the activities necessary to reach an organization’s goal. PMO/PdMOs can draft IAPDUs to determine the need, feasibility, and projected costs and benefits for service. 
  5. Provide an unbiased, third-party opinion 
    A PMO/PdMO will offer an unbiased, third-party opinion to help avoid misunderstanding and frustration, decision stalemates, inadequate solutions, and unpleasant relationships between WIC agencies and M&E vendors. 
  6. Provide the right combination of business and technical expertise
    Staffing challenges (exacerbated by COVID-19), difficulties finding expertise managing software change management for WIC, and a retiring workforce knowledgeable in WIC system implementation have in some cases left SAs without critical resources. Having the right combination of skills from a third party can resolve some of these challenges.

Independent SAs or MSCs would benefit from having a PMO/PdMO to help meet the challenges WIC agencies face today, whether it is an unplanned funding change or updates to the risk codes. With the help of a PMO/PdMO developing standard practices and methodologies, SAs and MSCs can deliver and implement high-quality services more consistently and efficiently. The role of the PMO/PdMO is far-reaching and positively impacts WIC by providing backbone support for WIC’s overarching goal, to “safeguard the health of low-income women, infants, and children who are at nutrition risk.”

If you have questions about PMOs or PdMOs and the impact they can have on your agency, please contact us. We're here to help.

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Product Management Office: Benefits for WIC state agencies

Read this if you are a behavioral health agency leader looking for solutions to manage mental health, substance misuse, and overdose crises.

As state health departments across the country continue to grapple with rising COVID-19 cases, stalling vaccination rates, and public heath workforce burnout, other crises in behavioral health may be looming. Diverted resources, disruption in treatment, and the mental stress of the COVID-19 pandemic have exacerbated mental health disorders, substance use, and drug overdoses.

State agencies need behavioral health solutions perhaps now more than ever. BerryDunn works with state agencies to mitigate the challenges of managing behavioral health and implement innovative strategies and solutions to better serve beneficiaries. Read on to understand how conducting a needs assessment, redesigning processes, and/or establishing a strategic plan can amplify the impact of your programs. 

Behavioral health in crisis

The prevalence of mental illness and substance use disorders has steadily increased over the past decade, and the pandemic has exacerbated these trends. A number of recently released studies show increases in symptoms of anxiety, depression, and suicidal ideation. One CDC study indicates that in June 2020 over 40% of adults reported an adverse mental or behavioral health condition, which includes about 13% who have started or increased substance use to cope with stress or emotions related to COVID-19.1 

The toll on behavioral health outcomes is compounded by the pandemic’s disruption to behavioral health services. According to the National Council for Behavioral Health, 65% of behavioral health organizations have had to cancel, reschedule, or turn away patients, even as organizations see a dramatic increase in the demand for services.2,3 Moreover, treatment facilities and harm reduction programs across the country have scaled back services or closed entirely due to social distancing requirements, insufficient personal protective equipment, budget shortfalls, and other challenges.4 These disruptions in access to care and service delivery are having a severe impact.

Several studies indicate that patients report new barriers to care or changes in treatment and support services after the onset of the pandemic.5, 6 Barriers to care are particularly disruptive for people with substance use disorders. Social isolation and mental illness, coupled with limited treatment options and harm reduction services, creates a higher risk of suicide ideation, substance misuse, and overdose deaths.

For example, the opioid epidemic was still surging when the pandemic began, and rates of overdose have since spiked or elevated in every state across the country.7 After a decline of overdose deaths in 2018 for the first time in two decades, the CDC reported 81,230 overdose deaths from June 2019 to May 2020, the highest number of overdose deaths ever recorded in a 12-month period.8 

These trends do not appear to be improving. On October 3, the CDC reported that from March 2020 to March 2021, overdose deaths have increased 29.6% compared to the previous year, and that number will only continue to climb as more data comes in.9  

As the country continues to experience an increase in mental illness, suicide, and substance use disorders, states are in need of capacity and support to identify and/or implement strategies to mitigate these challenges. 

Solutions for state agencies

Behavioral health has been recognized as a priority issue and service area that will require significant resources and innovation. In May, the US Department of Health and Human Services' (HHS) Secretary Xavier Becerra reestablished the Behavioral Health Coordinating Council to facilitate collaborative, innovative, transparent, equitable, and action-oriented approaches to address the HHS behavioral health agenda. The 2022 budget allocates $1.6 billion to the Community Mental Health Services Block Grant, which is more than double the Fiscal Year (FY) 2021 funding and $3.9 billion more than in FY 2020, to address the opioid epidemic in addition to other substance use disorders.10 

As COVID-19 continues to exacerbate behavioral health issues, states need innovative solutions to take on these challenges and leverage additional federal funding. COVID-19 is still consuming the time of many state leaders and staff, so states have a limited capacity to plan, implement, and manage the new initiatives to adequately address these issues. Here are three ways health departments can capitalize on the additional funding.

Conduct a needs assessment to identify opportunities to improve use of data and program outcomes

Despite meeting baseline reporting requirements, state agencies often lack sufficient quality data to assess program outcomes, identify underserved populations, and obtain a holistic view of the comprehensive system of care for behavioral health services. Although state agencies may be able to recognize challenges in the delivery or administration of behavioral health services, it can be difficult to identify solutions that result in sustained improvements.

By performing a structured needs assessment, health departments can evaluate their processes, systems, and resources to better understand how they are using data, and how to optimize programs to tailor behavioral health services and promote better health outcomes and a more equitable distribution of care. This analysis provides the insight for agencies to understand not only the strengths and challenges of the current environment, but also the desires and opportunities for a future solution that takes into account stakeholder needs, best practice, and emerging technologies. 

Some of the benefits we have seen our clients enjoy as a result of performing a needs assessment include: 

  • Discovering and validating strengths and challenges of current state operations through independent evaluation
  • Establishing a clear roadmap for future business and technological improvements
  • Determining costs and benefits of new, alternative, or enhanced systems and/or processes
  • Identifying the specific business and technical requirements to achieve and improve performance outcomes 

Timely, accurate, and comprehensive data is critical to improving behavioral health outcomes, and the information gathered during a needs assessment can inform further activities that support programmatic improvements. Further activities might include conducting a fit-gap analysis, performing business process redesign, establishing a prioritization matrix, and more. By identifying the greatest needs and implementing plans to address them, state agencies can better handle the impact on behavioral health services resulting from the COVID-19 pandemic and serve individuals with mental health or substance use disorders more efficiently and effectively.

Redesign processes to improve how individuals access treatment and services

Despite the availability of behavioral health services, inefficient business and technical processes can delay and frustrate individuals seeking care and in some cases, make them stop seeking care altogether. With limited resources and increasing demands, behavioral health agencies should analyze and redesign work flows to maximize efficiency, security, and efficacy. Here are a few examples of process improvements states can achieve through process redesign:

  • Streamlined data processes to reduce duplicative data entry 
  • Automated and aligned manual data collection processes 
  • Integrated siloed health information systems
  • Focused activities to maximize staff strengths
  • Increased process transparency to improve communication and collaboration 

By placing the consumer experience at the core of all services, state health departments can redesign business and technical processes to optimize the continuum of care. A comprehensive approach takes into account all aspects that contribute to the delivery of behavioral health services, including both administrative and financial processes. This helps ensure interconnected activities continue to be performed efficiently and effectively. Such improvements help consumers with co-occurring disorders (mental illness and substance use disorder) and/or developmental disorders find “no wrong door” when seeking care. 

Establish a strategic plan of action to address the impact of the COVID-19 pandemic

With the influx of available dollars resulting from the American Recovery Plan Act and other state and federal investments, health departments have a unique opportunity to fund specific initiatives to enhance the delivery and administration of behavioral health services. Understanding how to allocate the millions of newly awarded dollars in an impactful and sustainable way can be challenging. Furthermore, the additional reporting and compliance requirements linked to the funding can be difficult to navigate in addition to current monitoring obligations. 

The best way to begin using the available funding is to develop and implement strategic plans that optimize funds for behavioral health programs and services. You can establish priorities and identify sustainable solutions that build capacity, streamline operations, and promote the equitable distribution of care across populations. A few of the activities state health departments have undertaken resulting from the strategic planning initiatives include: 

  • Modernizing IT systems, including data management solutions and Electronic Health Records systems to support inpatient, outpatient, and community mental health and substance use programs 
  • Promoting organizational change management 
  • Establishing grant programs for community-driven solutions to promote health equity for the underserved population
  • Organizing, managing, and/or supporting stakeholder engagement efforts to effectively collaborate with internal and external stakeholders for a strong and comprehensive approach

The prevalence of mental illness and substance use disorder were areas of concern prior to COVID-19, and the pandemic has only made these issues worse, while adding more administrative challenges. State health departments have had to redirect their existing staff to work to address COVID-19, leaving a limited capacity to manage existing state-level programs and little to no capacity to plan and implement new initiatives. 

The federal administration and HHS are working to provide financial support to states to work to address these exacerbated health concerns; however, with the limited state capacity, states need additional support to plan, implement, and/or manage new initiatives. BerryDunn has a wide breadth of knowledge and experience in conducting needs assessments, redesigning processes, and establishing strategic plans that are aimed at amplifying the impact of state programs. Contact our behavioral health consulting team to learn more about how we can help. 

Sources:
Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, CDC.gov
COVID-19 Pandemic Impact on Harm Reduction Services: An Environmental Scan, thenationalcouncil.org
National Council for Behavioral Health Polling Presentation, thenationalcouncil.org
The Impact of COVID-19 on Syringe Services Programs in the United States, nih.gov
COVID-19 Pandemic Impact on Harm Reduction Services: An Environmental Scan, thenationalcouncil.org
COVID-19-Related Treatment Service Disruptions Among People with Single- and Polysubstance Use Concerns, Journal of Substance Abuse Treatment
Issue Brief: Nation’s Drug-Related Overdose and Death Epidemic Continues to Worsen, American Medical Association
Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic, CDC.gov
Provisional Drug Overdose Death Counts, CDC.gov
10 Fiscal Year 2022 Budget in Brief: Strengthening Health and Opportunity for All Americans, HHS.gov

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COVID's impact on behavioral health: Solutions for state agencies

Read this if you used COVID-19 relief funds to pay essential workers.

The Coronavirus Aid, Relief, and Economic Security (CARES) and American Rescue Plan (ARPA) Acts allowed states and local governments to use COVID-19 relief funds to provide premium pay to essential workers. Many states took advantage of this opportunity, giving stipends or hourly rate increases to government and other frontline employees who worked during the pandemic, such as healthcare workers, teachers, correctional officers, and police officers.

States’ initial focus was to get the money to the essential workers as quickly as possible, but these decisions may cause them to be out of compliance with the Fair Labor Standards Act (FLSA), which sets standards for minimum wage, overtime pay, and recordkeeping. As a result, states should review how the funds were disbursed and if payroll adjustments are necessary. The amount, form, and recipients of the pay varied widely from state to state, making determining whether states are compliant with FLSA and calculating any discrepancies an immensely complex task. 

For example, states that disbursed one-time payments to essential workers will likely be able to treat those payments like standard one-time bonuses, while recurring stipends or hourly rate increases should be included in employee’s regular rate when calculating overtime pay. Because this is an unprecedented situation for both states and the federal government, clear guidance is not yet available from the Department of Labor. 

Fortunately, BerryDunn is already working with clients to review their use of the COVID-19 relief funds to help ensure essential workers were paid fairly. Our team is qualified to guide you through your unique situation and help you remain in compliance with FLSA guidelines.

If you have questions about your particular circumstances, please call our Compliance and Risk Management consulting team. We are here to help and happy to discuss options to pay for these services using federal funds.

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Was your COVID-19 essential worker hazard pay FLSA-compliant?