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Using process redesign to align with new CYSHCN standards

By: Sarah Stacki,

Danni Ricks is a Consultant with the Government Consulting Group, specializing in Public Health. She is a Prosci® Certified Change Management Practitioner and experienced in process redesign, vendor management, and RFQ/RFP development.

Danni Ricks
11.12.20

CYSHCN programs have new care coordination standards―how does your agency measure up?

On October 15, 2020, the National Academy for State Health Policy (NASHP) released new care coordination standards for Children and Youth with Special Health Care Needs (CYSHCN) programs. The National Care Coordination Standards supplement the National Standards for Systems of Care, helping to ensure that children and youth with special health care needs receive the high-quality care coordination needed to address their specific health conditions.

The standards also set requirements for screening, identification, and assessment, a comprehensive shared plan of care, coordinated team-based communication, development of child and family empowerment skills, a well-trained care coordination workforce, and smooth care transitions. 

What do the standards mean for CYSHCN programs

The National Care Coordination Standards are more than guidelines for CYSHCN programs; aligning with the standards can lead to operational efficiencies, greater program capacity, and improved health outcomes. The standards can serve as a lens for continuous improvement, highlighting where programs can make changes that reduce the burden on care coordinators and program administrators.

However, striving to meet the standards can be challenging for many programs—as the standards develop and evolve over time, many programs struggle to keep up with the work required to update processes and retrain staff. Assessing a CYSHCN program’s processes and procedures takes time and resources that many state agencies do not have available. Despite the challenge, when state agencies are the most strapped is often when making change is the most needed. A shrinking public health workforce and growing population of CYSHCN means smooth processes are essential. To take steps towards National Care Coordination Standards alignment, BerryDunn recommends the following approach: 

A proven methodology for national standards alignment

There are many ways you can align with the standards. Here are three areas to focus on that can help you guide your agency to successful alignment. 

  1. Know your program
    It can be easy for processes to deteriorate over time. Process mapping is an effective way to shed light on current work flows and begin to determine holes in the processes. Conducting fact-finding sessions to map out exactly how your program functions can help pinpoint areas of strength―and areas where there is room for improvement.
  2. Compare to the national standards
    Identify the gaps with a cross-walk of your program’s current procedures with the National Care Coordination Standards. We assess your alignment through a gap analysis of the process, highlighting how your program lines up with the new standards.
  3. Adopt the changes and reap the benefits
    Process redesign can help implement the standards, and even small adjustments to processes can lead to better outcomes. Additionally, you can deploy proven change management methodologies programs that ease staff into new processes to produce real results.

Meeting national standards doesn’t have to be complicated. Our team partners with state public health agencies, helping to meet best practices without adding additional burden to program staff. We can help you take the moving pieces and complex tasks and funnel them into a streamlined process that gives your state’s children and youth the best care coordination. 

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Read this if you work at a public health department and would like a brief summary of how you can maximize funding and meet new federal requirements.

Unpacking the trillions

In response to the COVID-19 pandemic, several pieces of legislation were passed by congress and signed into law. The three bills, H.R. 6074 Coronavirus Preparedness and Response Supplemental Appropriations Act, H.R. 6201 Families First Coronavirus Response Act, and H.R. 748 Coronavirus Aid, Relief, and Economic Security (CARES) Act, have provided funding for various federal agencies with different roles in responding to the crisis. Because of the urgency required, much of the guidance for use of funds and reporting requirements were released after passage of the bills or have yet to be released.

Here is a brief timeline and summary of the acts:

Implication and next steps for state public health departments

While little guidance has been provided for how state public health departments should prepare to access federal funds, BerryDunn will continue to monitor and release updates as they become available. 

While at this point HR 6074 has the greatest implications for public health departments, here are some actions that states should take now for their public health programs from the recent legislation:

  1. H.R. 6074: Provides appropriations to the CDC to be allocated to states for COVID-19 expenses.
    • To ensure maximum funding, prepare a spend plan to submit to CDC.
    • To ensure compliance, provide CDC with copies or access to COVID-19 data collected with these funds.
    • To maximize the impact of new funding, develop a COVID-19 community intervention plan.
    • To support streamlined operations, submit revised work plans to CDC.
    • To prevent missed deadlines, submit any requests for deadline extensions to the CDC.
  2. H.R. 6201: Provides guidance specific to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs.
    • To encourage social distancing and loosen administrative requirements, seek waivers through the USDA’s Food and Nutrition Service (FNS).
    • To ensure compliance, prepare to submit a report summarizing the use of waivers on population outcomes by March 2021.
  3. H.R. 748: Allocates $150 billion to a coronavirus relief fund for state, local, and tribal governments.
  • To secure funding, monitor the US Department of Health & Human Services (HHS) for guidance on using funds for:
    • Coronavirus prevention and preparation
    • Tools to build health data infrastructure
    • COVID-19 Public Health Emergency expenses
    • Developing countermeasures and vaccines for coronavirus
    • Telehealth and rural health activities
       
  • To ensure HIPAA compliance when sharing protected patient health information, monitor the US Department of Health & Human Services (HHS) for guidance.

For more information

For specific issues your agency has, or if you have other questions, please contact us. We’re here to help. 

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COVID-19 laws and their impact on state public health agencies

Revolutionizing the way information is stored and received, blockchain is one of the most influential technologies of the past decade. Mostly known for its success with the digital payment system, Bitcoin, blockchain also has potential to transform the public sector, and further, the way citizens interact with government. Many states are considering this potential, but are stuck asking the most basic question: How can the public sector implement blockchain? The first step is to understand exactly what blockchain really is.

Blockchain—What is it?
At the highest level, blockchain is termed a Distributed Ledger Technology (DLT): data within a blockchain is not controlled by a single, centralized entity, but rather, is held by millions of systems simultaneously. This “chain” of systems, or DLT, not only decentralizes data, but also ensures it is incorruptible, as each “block” of data in the DLT connects using highly advanced encryption technology. Further, you can share each “block” without exposing the entirety of the blockchain’s data, enabling data sharing without compromising sensitive information. Blockchain’s opportunity lies in the core of its model, as being able to securely share records (containing sensitive information such as birth certificates, marriage licenses, property deeds, professional licenses, etc.), could connect different government services and create more efficient processes.

States across the nation are intrigued by the potential of blockchain, but unsure of just how to implement it successfully. Illinois, through the Illinois Blockchain Initiative, has been a leader in exploring blockchain’s possibilities in government. Here is some of their first-hand insight and advice.

Blockchain in Government—Illinois’ Perspective
Sunil Thomas, Cluster CIO, State of Illinois, assisted in the creation of the Illinois Blockchain Initiative in 2016, and is now a leader in testing and implementing blockchain technology across state services. BerryDunn connected with Sunil in August 2018, and he provided unique advice for other states considering a blockchain initiative.

Specifically, Sunil broke down the processes the Initiative used to advance the technology within the state, and shared three key pieces of advice for successful blockchain implementation:

  1. Host a statewide education campaign for blockchain to ensure all state leaders, including legislators, are equipped with a clear understanding of blockchain technology and its place in government. This education campaign may include extensive research into blockchain technology. Illinois, for instance, began their initiative by issuing a Request for Information (RFI) from vendors within the blockchain market. Additionally, Illinois collaborated with a local start-up that specializes in blockchain in order to gain subject matter expertise into blockchain development. 
  2. Initiate organized pilot projects to guide the direction of blockchain in the state and select what use cases should go through the full implementation process. At first, you should use blockchain projects to complement current state services. This ensures continuation of services, and allows for comprehensive transition time. Additionally, states should ask the questions: Why shouldn’t this service be delivered using a traditional solution?, and further, Why do we specifically need blockchain for this solution?, before each pilot. This will help you leverage the right services, with the greatest potential, as pilot blockchain projects.
  3. Create a statewide roadmap for blockchain to build an ecosystem that supports the technology. This “Blockchain Roadmap” should highlight a navigation plan for both state and federal regulations, and ensure that blockchain procurement strategies are understood. The roadmap can include a comprehensive cost-benefit analysis to determine a return on investment (ROI) for specific services considered for blockchain leverage. Overall, the roadmap will act as a guide throughout the entirety of the blockchain initiative, and will ensure the state’s vision for blockchain is achievable.

These key pieces of advice can provide a foundation for state’s looking to leverage blockchain to improve services; although each state should tailor blockchain technology to its specific needs. The Illinois Blockchain Initiative’s experience clearly demonstrates there is a way to navigate blockchain successfully in the public sector, and shows that the technology truly can assist in the transformation of government services moving forward.

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Blockchain in government: Advice from leaders at the Illinois Blockchain Initiative

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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Five things to keep in mind during your CCWIS transition

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

Click on the title to listen to the companion podcast to this article, Medicaid Enterprise Systems certification: Outcomes and APD considerations

Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline MES certification. During this time, we have been fortunate enough to be a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. The content we are covering is based on our experience supporting states with efforts related to CMS certification. We do not speak for CMS, nor do we have the authority to do so.

How does the focus on outcomes impact the way states think about funding for their Medicaid Enterprise Systems (MESs)?

Outcomes are becoming an integral part of states’ MES modernization efforts. We can see this on display in recent preliminary CMS guidance. CMS has advised states to begin incorporating outcome statements and metrics into APDs, Requests for Proposals (RFPs), and supporting vendor contracts. 

Outcomes and metrics allow states and federal partners to have more informed discussions about the business needs that states hope to achieve with their Medicaid IT systems. APDs will likely take on a renewed importance as states incorporate outcomes and metrics to demonstrate the benefits of their Medicaid IT systems.

What does this renewed importance mean for states as they prepare their APD submissions?

As we’ve seen with initial OBC pilots, enhanced operations funding depends upon the system’s ability to satisfy certification outcomes and Key Performance Indicators (KPIs). 

Notably, states should also prepare to incorporate outcomes into all APD submissions—including updates to previously approved active APDs that did not identify outcomes in the most recent submission. 
 
This will likely apply to all stages of a project’s lifecycle—from system planning and procurement through operations. Before seeking funding for new IT systems, states should be able to effectively explain how the project would lead to tangible benefits and outcomes for the Medicaid program.

How do outcome statements align with and complement what we are seeing with outcomes-based or streamlined modular certification efforts?

Outcomes are making their way into funding and contracting vehicles and this really captures the scaling we discussed in our last conversation. States need to start thinking about reprocurement and modernization projects in terms of business goals, organizational development, and business process improvement and redesign. What will a state get out of the new technology that they do not get today? States need to focus more on the business needs and less on the technical requirements.

Interestingly, what we are starting to see is the idea that the certification outcomes are not going to be sufficient to warrant enhanced funding matches from CMS. Practically, this means states should begin thinking critically about want they want out of their Medicaid IT procurements as they look to charter those efforts. 

We have even started to see CMS return funding and contracting vehicles to states with guidance that the outcomes aren’t really sufficiently conveying what tangible benefit the state hopes to achieve. Part of this challenge is understanding what an outcome actually is. States are used to describing those technical requirements, but those are really system outputs, not program outcomes.

What exactly is an outcome and what should states know when developing meaningful outcomes?

As states begin developing outcomes for their Medicaid IT projects, it will be important to distinguish between outcomes and outputs for the Medicaid program. If you think about programs, broadly speaking, they aim to achieve a desired outcome by taking inputs and resources, performing activities, and generating outputs.

As a practical example, we can think about the benefits associated with health and exercise programs. If a person wants to improve their overall health and wellbeing, they could enroll in a health and exercise program. By doing so, this person would likely need to acquire new resources, like healthy foods and exercise equipment. To put those resources to good use, this person would need to engage in physical exercise and other activities. These resources and activities will likely, over time, lead to improved outputs in that person’s heart rate, body weight, mood, sleeping patterns, etc.
 
In this example, the desired outcome is to improve the person’s overall health and wellbeing. This person could monitor their progress by measuring their heart rates over time, the amount of sleep they receive each night, or fluctuations in their body weight—among others. These outputs and metrics all support the desired outcome; however, none of the outputs alone improves this person’s health and wellbeing.

States should think of outcomes as the big-picture benefits they hope to achieve for the Medicaid program. Sample outcomes could include improved eligibility determination accuracy, increased data accessibility for beneficiaries, and timely management of fraud, waste, and abuse.
 
By contrast, outputs should be thought of as the immediate, direct result of the Medicaid program’s activities. One example of an output might be the amount of time required to enroll providers after their initial application. To develop meaningful outcomes for their Medicaid program, states will need to identify big-picture benefits, rather than immediate results. With this is mind, states can develop outcomes to demonstrate the value of their Medicaid IT systems and identify outputs that help achieve their desired outcomes.

What are some opportunities states have in developing outcomes for their MES modernizations?

The opportunities really begin with business process improvement. States can begin by taking a critical look at their current state business processes and understanding where their challenges are. Payment and enrollment error rates or program integrity-related challenges may be obvious starting points; however, drilling down further into the day-to-day can give an even more informed understanding of your business needs. Do your staff end users have manual and/or duplicative processes or even process workarounds (e.g., entering the same data multiple times, entering data into one system that already exists in another, using spreadsheets to track information because the MES can’t accommodate a new program, etc.)? Is there a high level of redundancy? Some of those types of questions start to get at the heart of meaningful improvement.

Additionally, states need to be aware of the people side of change. The shift toward an outcomes-based environment is likely going to place greater emphasis on organizational change management and development. In that way, states can look at how they prepare their workforce to optimize these new technologies.

The certification landscape is seemingly changing weekly as states wait eagerly for CMS’ next guidance issuances. Please continue to check back for in-depth analyses and OBC success stories. Additionally, if you are considering an OBC effort and have questions, please contact our Medicaid Consulting team

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Outcomes and APD considerations

Read this if you are an employee benefit plan fiduciary.

This article is the second in a series to help employee benefit plan fiduciaries better understand their responsibilities and manage the risks of non-compliance with Employee Retirement Income Security Act (ERISA) requirements. In our last article, we looked into the background of ERISA, which established important standards for the sound operation of employee benefit plans, as well as who is and isn’t a plan fiduciary, and what their responsibilities are. 

One important ERISA provision, found in Section 406(a), covers the types of transactions a plan fiduciary can and can’t engage in. ERISA terms the latter prohibited transactions, and they’re a lot like traffic lights—when it comes to avoiding conflicts of interest in business dealings, they’re your guide for when to stop and when to go. By knowing and abiding by these rules of the road, plan fiduciaries can steer clear of tickets, fines, and other damaging mishaps. 

Parties-in-interest—keep them out of the passenger seat 

Much like driver’s ed., fiduciary responsibility boils down to knowing the rules—plan fiduciaries need to have a strong working knowledge of what constitutes a prohibited transaction in order to ensure their compliance with ERISA. The full criteria are too detailed for this article, but one sure sign is the presence of a party-in-interest.

ERISA’s definition of a party-in-interest

The definition includes any plan fiduciary, the plan sponsor, its affiliates, employees, and paid and unpaid plan service providers, and 50%-or-more owners of stock in the plan sponsor. If you’d like to take a deeper dive into ERISA’s definition of parties-in-interest, see “ERISA's definition of parties-in-interest" at right.

Prohibited transactions—red lights on fiduciary road 

Now that we know who fiduciaries shouldn’t transact with, let’s look at what they shouldn’t transact on. ERISA’s definition of a prohibited transaction includes: 

  • Sale, exchange, and lease of property 
  • Lending money and extending credit 
  • Furnishing goods, services, and facilities 
  • Transferring plan assets 
  • Acquiring certain securities and real property using plan assets to benefit the plan fiduciary 
  • Transacting on behalf of any party whose interests are adverse to the plan’s or its participants’ 

Transacting in any of the above is akin to running a red light—serious penalties are unlikely, but there are other consequences you want to avoid. Offenders are subject to a 15% IRS-imposed excise tax that applies for as long as the prohibited transaction remains uncorrected. That tax applies regardless of the transaction’s intent and even if found to have benefited the plan. 

The IRS provides a 14-day period for plan fiduciaries to correct prohibited transactions and avoid associated penalties. 

Much like owning a car, regular preventative maintenance can help you avoid the need for costly repairs. Plan fiduciaries should periodically refresh their understanding of ERISA requirements and re-evaluate their current and future business activities on an ongoing basis. Need help navigating the fiduciary road? Reach out to the BerryDunn employee benefit consulting team today. 
 

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Prohibited transactions: Rules of the road for benefit plan fiduciaries

Read this if you’re considering (or in the middle of) an initiative that involves multiple Health and Human Services (HHS) programs or agencies.

During times of tight program budgets and rising need, the chance to collaborate with sister HHS agencies often presents a unique opportunity to do more with less. However, as you might find, these initiatives have their own challenges ranging from the minor (e.g., different program vocabulary) to major considerations (e.g., state and federal funding streams).

While interagency initiatives are worthwhile—usually aiming to reduce silos between HHS programs and better support citizens and staff—they can quickly grow complicated. Whether you’re just starting to think about your next interagency initiative or you’re halfway through, asking the right questions is half the battle. Answering those questions, of course, is the other—and more time-consuming—half!

In our team’s work with states on interagency initiatives, we have found it helpful to focus planning on the following four areas to minimize implementation timelines and maximize stakeholder support:

  • Policy: The sources, both internal and external, that govern who is covered by programs, what services are covered, how services are reimbursed, and how the program is administered
  • Funding: How a program is financed, including cost allocation methodologies, limitations on use of funds, and reporting mechanisms
  • Systems: The technical infrastructure that supports program operations
  • Operations: The staff and physical facilities that make every program possible, including staff resources such as training

Here are some questions you can ask to make the best use of available time, funding, and interagency relationships:

  • What is the goal? Do other departments or units have an aligning goal? Who do you know at those departments or units who could direct you to the best point of contact, the status of the other department or unit’s goal, and the current environment for change? Perhaps you can create a cross-unit team with the other unit(s), resulting in more resources to go around and stronger cross-unit relationships. If the other unit either isn’t ready or has already implemented its change, learning about the unit’s barriers or lessons learned will inform your efforts.
  • What does your governance model look like? Do you have one decision-maker or a consensus-builder leading a team? How does your governance model incorporate the right people from across all agencies so they have a voice? If the process is collaborative, can an oversight entity play a role in resolving disagreements or bottlenecks? Without a governance model, your team might be composed of subject matter experts (SMEs) who feel they do not have authority to make decisions, and the project could stall. On the other hand, if you only have leadership positions on the team without SME representation, the project plan might miss critical factors. Having the right people at the table—with defined lines of expertise, authority, and accountability—increases your chances of success.
  • Which federal partners are involved, who are the points of contact, and how open are they to this change? In addition to providing necessary approvals that could lead to funding, federal partners might offer lessons learned from other states, flexibilities for consideration, or even a pilot project to explore an initiative with you and your state partners. 
  • How will this initiative be funded? If more than one funding stream is available—for example, federal financial participation, grant dollars, state dollars—can (and should) all funding streams be utilized? What requirements, such as permissible use of funds and reporting, do you need to meet? Are these requirements truly required, or just how things have always been done? Some federal matches are higher than others, and some federal dollars can be combined while others must remain separate/mutually exclusive to be reimbursed. One approach for using multiple sources of funding is “braiding”—separate strands that, together, form a stronger strand—versus “blending,” which combines all sources into one pot of funding.
  • What systems are involved? After securing funding, system changes can be the largest barrier to a timely and effective interagency initiative. Many state agencies are already undertaking major system changes—and/or data quality and governance initiatives—which can be an advantage or disadvantage. To turn this into an advantage, consider how to proactively sync your initiative with the system or data initiative’s timing and scope.
     
    • When and how will you engage technical staff—state, vendor, or both—in the discussion?
    • Do these systems already exchange data? Are they modernized or legacy systems? 
    • Do you need to consult legal counsel regarding permissible data-sharing? 
    • Do your program(s)/agencies have a common data governance structure, or will that need to be built? 
    • What is the level of effort for system changes? Would your initiative conflict with other technical changes in the queue, and if so, how do you weigh priority with impacts to time and budget?
  • What policies and procedures will be impacted, both public-facing and internally? Are there differences in terminology that need to be resolved so everyone is speaking the same language? For example, the word “case” can mean something different for Medicaid business staff, child welfare staff, and technical staff.
  • Will this initiative result in fewer staff as roles are streamlined, or more staff if adding a new function or additional complexity? How will this be communicated and approved if necessary? While it’s critical to form a governance model and bring the right people to the table, it’s also imperative to consider long-term stakeholder structure, with an eye toward hiring new positions if needed and managing potential resistance in existing staff. For the project to have lasting impact, the project team must transition to a trained operations team and an ongoing governance model.

Ultimately, this checklist of considerations—goal-setting, decision-making, accountability, federal support, funding, systems, policies and procedures, and staffing—creates a blueprint for working across programs and funding streams to improve services, streamline processes, and better coordinate care.

For more information about interagency coordination, stay with us as we post more lessons learned on the following topics in the coming months: interagency policy, interagency funding, interagency systems, and interagency operations.
 

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Coordinating initiatives across state HHS: Questions to ask

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

This article is based on the Outcomes-Based Certification scalability and project outcomes podcast:


Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline MES certification. During this time, we have been fortunate enough to be a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. The content we are covering is based on our experience supporting states with efforts related to CMS certification. We do not speak for CMS, nor do we have the authority to do so.

How might Outcomes-Based Certification (OBC) be applied to more complex areas of the Medicaid enterprise?

The question of scaling—that is, to apply the OBC process to more complex components while maintaining or increasing its level of efficiency—is an important next step in certification. OBC has been (or is being) scaled across the technical components of the MES in two primary ways. First, OBC has already successfully been scaled horizontally across similar but discrete components of the MES such as electronic visit verification (EVV), provider management, or pharmacy. The second, perhaps more interesting way we are seeing OBC scale is vertically. OBC—or what is now being referred to as Streamlined Modular Certification (SMC)—is now being scaled up and into larger and more complex components like financial management and claims processing. Beyond that, however, we are now seeing outcomes-based concepts scale a third way—across the Medicaid business.

How does the certification of one module impact the rest of the MES?

We are seeing CMS and states work through this question every day. What we know for sure is that each state is likely going to draw its own set of boxes around its business modules and service components based on its Medicaid business. Because modularity is only defined at a macro level, states have the freedom to work with their vendors to define the parameters of their modules. As a result, we have seen CMS work with states to define those boxes and in doing so, we are really seeing a three-layered approach.

The first layer represents the primary module a state is certifying. A primary module is that module that is responsible for all or most of a business process such as paying a claim. It is safe to assume that the most detailed evidence will come from the primary module. The second layer represents the module—or modules—that might not have responsibility for a business process, but provide functionality integral to that business process being performed successfully. Finally, the third layer represents the module—or modules—that feed data into the business process, but do little else when it comes to performing that business process. For the second and third layer, a state can likely expect to provide evidence that supports the successful transmission of data at a minimum. This is where we are seeing CMS and states work together to define that scope.

What is the role of business process improvement, organization development, and organizational change management in MES modernizations?

This is really the cornerstone of this fundamental shift in certification we have seen over the last 12-18 months. During the 2020 virtual Medicaid Enterprise Systems Conference (MESC), we saw that CMS appears to be signaling it is no longer going to readily accept modernization efforts that do not reflect tangible improvements to the Medicaid business. Think about it this way: a state will likely not be able to go to CMS to request enhanced funding simply because it can no longer renew its existing contract vehicles or it is trying to procure new technology that fails to represent a marked improvement over its legacy system. 

As a result, states need to start thinking about reprocurement and modernization projects in terms of organizational development and business process improvement and redesign. What will a state get out of the new technology that they do not get today? That’s the question that needs to be answered. States should begin to focus more on business needs and less on technical requirements. States are used to building a custom, monolithic enterprise, often referred to as a Medicaid Management Information System (MMIS). Today, vendors are bringing commercial-off-the-shelf (COTS) products that allow states to perform business processes more efficiently. In turn, states need to move away from attempting to prescribe how a system should perform and focus on what the system should do. That means less prescriptive requirements and more business-oriented thinking.

Additionally, the concept of outcomes management will become integral to a state’s Advance Planning Document (APD) requests, Request for Proposals (RFP) development, and certification. We are seeing that CMS is beginning to look for outcomes in procurement documents, which is leading states to look critically at what they want to achieve as they seek to charter new projects. One way that a state can effectively incorporate outcomes management into its project development is to identify an outcome owner responsible for achieving those outcomes.

The certification landscape is seemingly changing weekly, as states wait eagerly for CMS’ next guidance issuances. Please continue to check back for in-depth analyses and OBC success stories. Additionally, if you are considering an OBC effort and have questions, please contact our Medicaid Consulting team

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Scaling project outcomes

Read this if you are a division of motor vehicles, or interested in mDLs.

What is a mobile driver’s license?

A mobile driver’s license (mDL) is a solution that allows citizens to access, update, and use their driver’s license via a smart phone or other internet-accessible device (e.g., laptop, tablet, smart watch). An mDL is a form of electronic identification (eID), but where eIDs include other forms of licensure like hunting/fishing/gaming licenses or military IDs, mDLs are used to designate driving privileges and, in some cases, to designate age-based/identity privileges for citizens who cannot drive (e.g., buying alcohol, TSA PreCheck®).

Why should you care?

Technology has replaced physical product functionality within various areas of modern life. Many people have transitioned to electronic credit/debit card payments (e.g., Apple Pay), making paying for everyday items faster, easier, and cleaner, while also introducing risks to consumer data security. Similar functionality will soon exist within the eID space, starting with mDLs. This provides challenges for departments of motor vehicles (DMVs), businesses, and consumers; however, the benefits of adopting mDL functionality outweigh the growing pains of establishing the programs.

How does it work and when will it be implemented?

The mDL will function similarly to electronic credit cards and mobile payment applications: an mDL user loads their mDL to their mobile device using a mobile application and can use it to verify their age and driving credentials at mDL-reading establishments and with law enforcement. Relevant establishments will require both hardware and software solutions to read mDLs. 

mDLs aren’t intended to replace physical licenses—at least not yet. While state and county pilot programs resolve some of the challenges associated with mDLs, physical IDs will remain required for years to come. 

Additionally, the American Association of Motor Vehicle Administrators (AAMVA) created two groups—a Card Design Standard Committee and Electronic Identification Working Group—to develop interoperable standards to assist license issuing authorities (e.g., DMVs) in developing their mDL programs. These standards will ensure that mDLs work using different hardware, software, vendor applications, and within different jurisdictions. 

Benefits and challenges

Benefits

mDLs provide numerous benefits to citizens and DMVs alike, including information security, user convenience, and administrative convenience.

Information security

  • mDLs are harder to fake than physical driver’s licenses due to the mDL’s connection to back-end license data within the DMV system. 

  • mDLs allow users the option to communicate specific data to the receiving party without sharing all of the user’s license information (e.g., confirming the user is over age 21 without sharing their specific age or street address). 

User convenience

  • Users will be able to update their credentials fully online and see in-real-time updates.
  • mDLs will possess single sign-on verification and use for users via a biometric lock or PIN, making them quick to access and easy to use.

Administrative convenience

  • The decline in DMV wait times due to online-update functionality will save DMVs money in administrative costs.

Challenges

As with all technological advancement, there are several challenges around the development of mDLs. The primary challenge is ensuring the protection of user data while also rolling out the complex—and often costly—infrastructure needed to support mDL use across a region. 

Information security 

  • Issuing agencies can choose whether some, none, or all mDL user data is stored on the user’s device and must ensure all data stored this way is done so securely.

  • mDLs must ensure hands-free exchange of information with law enforcement to protect user data when presenting identification.

  • Technological errors are bound to occur: if an mDL-reading establishment is not able to read a citizen's mDL for any reason, a citizen will require a physical license to complete the transaction.

Program rollout

  • States and mDL vendors will need to support interoperable mDL standards to ensure that an mDL works with different vendor software and across jurisdictions.

  • Establishments and law enforcement will need the necessary mDL-reading hardware (smart phone, smart watch, tablet, laptop, point-of-sale terminal) and software (QR code readers, Bluetooth functionality, Wi-Fi Aware, Nearfield Communication, etc.) to read mDLs.

  • mDLs must be able to function in both offline and online scenarios to ensure the security of consumer data and proper functionality.

The future

mDLs are just the beginning of the opportunities eID technology will bring. Once established by DMVs, eID technology can and will be used to find and buy insurance services, check medical prescriptions, apply for social/welfare benefits, open hunting/fishing/gaming accounts and display appropriate credentials, and access pension information. 

The versatility that eID technology provides will streamline American citizens’ identification arsenal, and the advancing mDL technology puts us on the path to get there. The question is not will mDLs become widespread, but when.
 

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Introduction to mobile driver's licenses (mDLs): What are they and why are they important?