A System to Support Diverse Social Program Management

Introduction

Government and community-based organizations are responsible for delivering social services to clients through social programs provided at the national, state, county, and city levels. Social programs are critical to the health and welfare of many citizens, as they provide a wide range of benefits [1], such as (1) health and human services for health insurance, prevention services, child welfare, and nutrition assistance; (2) workforce services for unemployment insurance programs and job training; and (3) social security programs offering income support and benefits [2].

In contrast to commercial entities, government agencies administering social programs face unique challenges regarding service delivery and their operational processes, including (1) information silos that limit decision-making abilities, (2) requirements to balance privacy with data sharing and transparent use of public funds, (3) reduced financial resources but growing demand for services, (4) legislative and organizational influences on eligibility and entitlement, and (5) the need to document the delivery of mandated services for beneficiaries across multiple categorical programs [3,4]. These challenges are exacerbated by societal shifts, such as increasing income inequality, aging populations, unemployment, ongoing changes in government policies, and resource constraints [5-7].

Opportunities exist for information technology to address these challenges by improving the efficiency and transparency of social program workflows and enabling collaboration among stakeholders. These goals can be achieved by centralizing critical data, streamlining eligibility determination and case management, and improving communication within and across organizations [8]. Previous preliminary research indicates that the use of information systems to support high-quality and efficient service delivery is promising but limited in scope and does not meet the unique needs of social programs [8-10]. Comprehensive systems specifically designed for social programs have not been previously described in the literature.

This viewpoint describes the design, functionality, and selected applications of a software solution for social services, which combines domain-specific business processes with a flexible open architecture to allow for needed configurability while standardizing data elements. Specific design principles that aim to address the unique challenges encountered by social programs, along with examples of implementation and usage, are described.

Our system was designed and developed by subject matter experts in social programs, including industry specialists, service professionals experienced in social programs, and social program product developers. The system was developed for social service and human service agencies to advance digital transformation, intending to support a wide range of constituents across the health and human services enterprise. Potential users include, but are not limited to, Medicaid program managers, directors, analysts, caseworkers and care managers, clients, and beneficiaries. The system aims to prioritize the needs of users and beneficiaries to unify multidisciplinary teams. User-centered research methods, including user shadowing, interviews, surveys, and scenario testing, were used to identify user needs, and human-centered design leveraging iterative co-development and prototyping were used to develop the system.

System Scope

Social Program Management (SPM) supports two basic types of social programs: (1) programs in which eligibility is determined primarily based on need and (2) programs where eligibility for benefits and services is determined based on previous contributions [11,12]. SPM also supports care and protection programs, such as child welfare programs, where eligibility is based on practice models and assessments; Figure 1 describes the full scope and scale of service organizations that SPM supports.

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These diverse social programs share similar goals and challenges with the aim of improving service delivery to and outcomes for beneficiaries. To meet these goals, social programs require systems that (1) support complex eligibility and entitlement, (2) provide beneficiaries with easy access to services, (3) enable efficient management of high case volumes, (4) provide decision support and knowledge management tools, (5) allow flexibility for changes in policies and processes, and (6) reduce the potential for fraud and abuse. These needs must be met throughout triage, initial contract and registration, determination of eligibility for benefits, service planning and delivery, and outcome evaluation. Delivering services across these program stages relies on secure data gathering, documentation, retrieval, validation, auditing, and analysis. SPM has features and capabilities that address each of these needs (Table 1) [13].

System Architecture

Overview

The features and functionalities described in Table 1 are organized within a single user-centered system comprising modules, the SPM data model, administration application, and business and technical services. The architecture for SPM version 7.0.9, the latest version, is outlined in Figure 2, and the modules and applications of the SPM are described in the following sections (see Multimedia Appendix 1 for technical aspects of SPM).

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SPM Modules

The SPM modules presented in Table 2 support repeatable processes that are common across programs. These processes include managing client information and data regarding benefits, automatic assessment of eligibility and entitlement, management of tasks, communication, and scheduling. Each module is supported by the SPM platform, including the data model and administrative, business, and technical services. The SPM modularization supports the incremental modernization of systems used by social programs. As the data model is application-agnostic, the integration of future modules or functionalities is supported. These modules support a comprehensive range of functionalities required for service delivery in social programs. Modules are divided by those that exist for all implementations of SPM (enterprise-wide applications) and those specific to a particular implementation and user agreement (implementation-specific modules).

System Usage and Case Reports

The latest version of SPM has been used by more than 50 programs in 13 countries (Figure 3) and 13 languages. In total, more than 280,000 caseworkers worldwide have used SPM with 30 million beneficiaries.

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Case Report 1: User-Centered Design for Social Program Efficiency

Eligibility and entitlement determination are often complex, time-consuming, and one of the most frustrating aspects of social program service delivery for administrators and clients. A large US city department of human resources used SPM’s universal access module to redesign their Supplemental Nutrition Assistance Program (SNAP) [14] to digitize services and reduce wait times compared with manual processing of applications and limit the need for in-person visits.

In April 2018, the city implemented a citizen-facing portal, available in 7 languages, to deliver the SNAP and other benefits via clients’ own desktop and mobile phones. The design of the portal was informed by 30 shadowing sessions, 10 interviews, and 20 scenario testing sessions. Iterative prototyping and co-design workshops were also conducted to refine the portal design.

A retrospective pre-post comparison of SPM metrics (ie, web and mobile log-ins, web-based applications and recertifications, and calls to update profile information) was conducted using monthly data collected in April 2018 and April 2019 (Table 3). The median age of the SNAP recipients was 25 to 44 years, and most were women (870,000/1,523,502, 57.11%). With regard to ethnic background, 27.83% (424,050/1,523,502) were Black only, 24.43% (372,245/1,523,502) were Hispanic and White only, 10.35% (157,723/1,523,502) were Black and Hispanic only, 11.23% (171,157/1,523,502) were multiethnic, 14.6% (222,495/1,523,502) were White, 10.29% (156,813/1,523,502) were Asian, and 1.25% (19,019/1,523,502) were of other ethnicities.

In the assessed periods, application rejections because of failure to provide documentation were reduced by 20% from 2674 in April 2018 to 2139 in April 2019 and center visits were reduced by 37% from 71,116 in April 2018 to 44,803 in April 2019. Of the 30,000 SNAP applications submitted in August 2019, 80% were submitted on the web through client-mobile devices via SPM’s universal access module. Client experience satisfaction was also measured with a web-based 5-star rating survey emailed to participants after they completed the application process. Responses (27,128) were collected with an average rating of 4.31 out of 5 (5 being the highest; 1 being the lowest) for the SNAP application and 4.44 out of 5 for the SNAP recertification.

Case Report 2: Flexibility and Standardization in Digital Transformation

A US state’s health and human services department designed a program to improve the way state county departments provided services to families and allow caseworkers to spend less time on administrative tasks and more time helping individuals and families. Specifically, the state wanted real-time data sharing and aggregation across different health and human services divisions. At the time, most families were served through multiple categorical programs. Concurrently, the state wanted to limit the amount of system customization for each county yet be flexible enough to allow each to use legacy systems in a consolidated system managing all benefits and services until legacy systems could be sunset.

SPM was implemented in 2012, and information technology systems were modernized in more than 100 counties for 8 years. Deployments of SPM were designed to be interoperable with legacy systems so that incremental rollout could occur [15]. SPM has replaced or is in the process of replacing approximately 20 legacy systems with a single one. SPM’s common data model provides data sharing; therefore, caseworkers no longer need to enter data into multiple systems, spending less time on administrative tasks and more time assisting families. Participants’ administrative data can be viewed and shared in real time to support a holistic view of the client, their needs, and the analysis of progress toward goals and programmatic outcomes. Currently, at least 3.5 million individuals across the state have been provided benefits through SPM [16].

Case Report 3: Data Aggregation, Sharing, and Collaboration

In a large city in Germany, 7 local districts and 40 regional agencies are responsible for protecting children from abuse. Two special government organization units support these districts and agencies in defining and monitoring policies and providing financial and technical resources. In an effort to provide better outcomes and serve clients more efficiently, the government sought to use SPM to improve processes for client intake, case management, and communication between agencies. Specific needs included improving upon reports of abuse, traditionally done through telephone and fax machines, and better data sharing and collaboration. The government leveraged the SPM platform to address these needs, including applications for verification of evidence and provider management for managing interactions between the government and local agencies, such as foster care. Implementation-specific modules included the social enterprise collaboration for supporting multidisciplinary teams and the child welfare module for managing child abuse cases. The solution was implemented in stages where standards for social services relevant to child abuse cases, such as foster care, were defined; an interface among SPM, legacy systems, and systems of local agencies was then deployed. In the second stage, modules for managing clients were implemented. These modules provided local agencies and the government with case management capabilities for documenting and sharing information related to interactions with children and families, services, contacts, worker visits, and judicial processes.

SPM allows caseworkers to view and manage a wide range of information in one place, from the initial receipt of an allegation through the final case outcome. This information enables bidirectional information sharing among local agencies and can then be used to document outcomes digitally. For example, when an allegation is made, supporting information such as police reports is automatically imported into SPM. As of June 2019, SPM in this city had 1300 users, 370,000 clients, and more than 200,000 cases and processed approximately 50,000 transactions per month since its implementation in 2014. This represents an average increase of 60% in the number of cases processed per year compared with the legacy system.

Discussion

Overview

We presented a configurable and modular system that delivers integrated cross-program and cross-agency solutions for needs-based and contribution-based social service programs [3,17-21]. Although social programs provide a wide variety of benefits across distinct and heterogeneous populations, fundamental needs are shared across programs that deliver services. SPM provides a set of functionalities that are generalizable and support government agencies and their beneficiaries across diverse program types and locations. These functionalities are configurable and adaptable to address the unique context of each social program.

The flexibility of SPM provides advantages in implementation and change management for the digital transformation of social programs. Most legacy social program systems have automated key program processes. Usually developed ad hoc, these older systems are complex, heterogeneous, and high maintenance. At the same time, these organizations tend to be risk-averse and often dependent on specific products or platforms [22]. Rather than imposing a need to redevelop the entire technology infrastructure, SPM can provide an interface between new solutions and legacy systems through modularity and open standards.

Finally, data aggregation and sharing are important for improving outcomes and tracking program success by reducing information gaps and providing a holistic view of clients. Previous research has demonstrated that integrated case management with a multidisciplinary approach may improve positive outcomes for clients [23]. SPM supports comprehensive data on service delivery for accountability and caseworker decision-making through a common data model. At the same time, a combination of business and infrastructure security mechanisms keeps client data protected and secure during program or agency collaboration, supporting trust in social programs.

This system description is limited in that the implementations described are on-premise solutions currently. Data quality and silos can limit the extent of insights and analytics, and how these data are presented influences decision-making. Improving program performance and achieving better health outcomes requires bringing together and presenting data visually to enhance decision-making abilities. These are common challenges for any enterprise-wide solution. We have made the platform more flexible and portable by moving more core processes of SPM to the cloud. We have released SPM to work on an open-source container application platform so that users can secure and use their data across multiple environments, including public and private clouds. We are also providing analytic capabilities across social programs and in a visual format at the point of decision-making to better assess the impact of social programs on health outcomes.

This viewpoint highlights the features of SPM with use cases selected to illustrate its generalizable features, such as benefits management, health and human services administration, and case coordination. These case studies were limited by organizations that were willing to share data and participate in the research. We were not able to design metric collection a priori, so the data for each use case are based on what could be provided by participating organizations.

Conclusions

SPM is a user-centered, configurable, and flexible system designed to manage social program workflows. Its features and functionalities support the goals of social programs through improved service delivery to beneficiaries with functionalities and features for complex eligibility and entitlement, convenient access to services, complex case management, organizational and policy change management, and program transparency. More than 50 government organizations, 280,000 caseworkers, and 30 million beneficiaries are served through SPM, demonstrating the flexibility and scalability across social program types and settings in designing administrative systems that support a streamlined workflow.