HUMAN SERVICES RESTRUCTURING TASK FORCE

November 4, 1997 - Second Meeting of Four

MEMBERS PRESENT

• Senator Maggie Tinsman, Co-chairperson
• Senator Nancy Boettger
• Senator Patricia Harper
• Senator Gene Maddox
• Senator Patty Judge
• Representative William Brand
• Dr. James Austin
• Arlene Dayhoff
• Thomas A. Wilson

MEETING IN BRIEF

Minutes prepared and organization staffing by Patty Funaro, Sr. Legal Counsel

1. Procedural Business.
2. Council on Human Investment -- State Policy Objectives -- Budgeting for Results.
3. Documents for Subsequent Review.
4. Panel of Directors.
5. Discussion With Panel.
6. State Children's Health Insurance Program (SCHIP).
7. Family Support Work Group.
8. Local Forum Reports.
9. Subcommittee Discussion of Future Plans.
10. Next Scheduled Meeting.
11. Materials on File With the Legislative Service Bureau.

SUBCOMMITTEE BUSINESS

1. Procedural Business.

The second meeting of the Program Duplication and Resource Utilization Subcommittee of the Human Services Restructuring Task Force was held on Tuesday, November 4, 1997, in Room 118 of the State Capitol. The meeting convened at 10:15 a.m. and adjourned at 3:40 p.m.

Correction. The Subcommittee approved the meeting summary of the September 10, 1997, meeting. However, the copies distributed should have included Senator Patricia Harper as being present at that meeting. A corrected copy of the meeting summary of the September 10, 1997, meeting is on file with the Legislative Service Bureau.

2. Council on Human Investment -- State Policy Objectives -- Budgeting for Results.

Council on Human Investment. Mr. Marv Weidner and Ms. Mary Noss Revealy, Department of Management, presented information regarding the development of a results-based performance management system in Iowa. The Council on Human Investment (CHI) was created through legislation in 1993 as a 13-member, bi-partisan citizen council, chaired by the Lieutenant Governor. The charge to CHI was to develop and implement a performance management system for state government.

Research. A research group was established through CHI to conduct statistically valid opinion polls, and surveys and focus groups were also used to determine the priorities of Iowans. These priorities have been set forth in a listing of 22 state policy objectives. A Performance Measurement Task Force comprised of state agency representatives with data analysis, measurement, and planning expertise then coordinated the development of performance measurements for the State Policy Objectives.

Budgeting for Results. Mr. Weidner and Ms. Revealy noted that one way in which the State Policy Objectives are used is in budgeting for results (BFR), which is a way to measure the impact of state agency efforts on the lives of Iowans by answering the question, "What result did I (the taxpayer) get for my money?" Objectives or desired results are used to determine appropriation of resources, and appropriation of resources is tied to the actual results achieved through that appropriation.

Governor's Strategies. They noted that another grouping of the 22 objectives, the Governor's State Policy Objectives, prioritize the state policy objectives and are the Governor's long-term, measurable results that integrate the efforts of multiple agencies. The Governor's State Policy Objectives are developed through the Iowa State Government's Enterprise Strategic Planning Process which brings agency directors together in Planning Teams to develop strategic plans to achieve the Governor's Leadership Agenda -- which includes Goals, Strategies, and the Governor's State Policy Objectives. The Planning Teams develop a vision for each Strategy and from this they recommend a select listing of Governor's State Policy Objectives. The Governor's Strategies are umbrellas under which State Policy Objectives are listed which pertain to that Strategy. Mr. Weidner and Ms. Revealy said that BFR is to be fully implemented in all state agencies by the year 2000.

Process Explanation. Mr. Weidner described the aspects of BFR as the State Policy Objectives being the statements of policy objectives, programs as being the activities undertaken to realize the objectives, the program purpose statements being the intent/mission of the program, the program results measure being the description of how the program benefits the stakeholder, and a data collection plan being the plan which is used to measure results. Mr. Weidner described the BFR process as one in which all of the other aspects of the process flow from the overall goal or State Policy Objective which allows planning, programming, and budgeting to be accomplished across agency lines based upon the same objective.

Discussion. During discussion with Subcommittee members, Ms. Revealy and Mr. Weidner noted that using BFR adds a measure of accountability to state agency efforts and that progress in achieving State Policy Objectives is measured along a curve rather than in specific increments or in inputs and outputs. In discussing Innovation Zones, Mr. Weidner noted that the Innovation Zones also can use the State Policy Objectives to align state and local efforts.

3. Documents for Subsequent Review.

The Subcommittee received two documents for later review. One, entitled "Iowa Programs for Children," is a matrix developed by the Legislative Fiscal Bureau (LFB) which includes all programs, identified under the purviews of the Departments of Human Services, Public Health, Human Rights, Education, and Workforce Development, which relate to children and their families. The matrix is broken down by populations served including the prenatal population, children ages 0-5, children ages 6-18, and holistic programs serving children and their families. Ms. Margaret Buckton, LFB, briefly described the information included in the chart and asked that the members review the matrix for discussion at a later meeting. The Subcommittee members also received a handout entitled "Evaluation Proposal Considerations." The handout was developed by Ms. Buckton following a discussion with Representative Wayne Ford. The proposal will be considered at a later meeting.

4. Panel of Directors.

Overview. Mr. Charles Palmer, Director, Department of Human Services; Mr. Ted Stilwill, Director, Department of Education; and Mr. Chris Atchison, Director, Iowa Department of Public Health, discussed interagency collaboration efforts with the Subcommittee. Each of the Directors, in turn, discussed an aspect of collaboration.

Collaboration History. Director Atchison began by discussing the historical development of collaboration between the departments and with local entities. He provided a document entitled "State Government is One Enterprise," which demonstrates the various collaborative efforts throughout the years, all with the goal of achieving strong families. These efforts include the Strong Families Work Group, the involvement of the Danforth Foundation and the Annie E. Casey Foundation, the development of Innovation Zones as the central mechanism for devolution, the Council of Chief State School Officers which provides for peer consulting across state lines, and the Governor's Enterprise-Wide Strategic Plan which provides a process through which long-term results involving multiple agencies can be developed. Director Atchison also described other efforts such as the Council on Human Investment and the development of a performance management system with the use of budgeting for results, the development of decategorization, and other instances of local involvement in the collaborative effort to build strong families.

Director Atchison noted that there are enduring responsibilities of government and that using a performance-driven system with overall objectives provides government with an established framework for meeting these essential responsibilities, rather than government merely responding to the most current problem. He also remarked that the state realizes the importance of inclusion of the local communities in state level planning. Director Atchison described one of the Governor's Strategies which is to support stable, self-sufficient, healthy, and safe families, discussed critical issues affecting families which might be obstacles to achieving this objective and discussed four basic strategies to address each of the critical issues. The strategies include service system redesign, community capacity building, early childhood development, and information/technology.

Partnership Examples. Director Stilwill provided examples of partnerships between the agencies. He noted that the role of state government is to assist local communities in successfully meeting the needs of their citizens and to act as a centerpiece for collaboration by clarifying results to be achieved from the state perspective, allowing each community to determine the results to be achieved at the community level, and matching the two.

Director Stilwill described the work of the Family Strategy Work Group, which includes the directors, key staff, representatives of the Department of Management, and the Governor's office and which is chaired by the Lieutenant Governor, as an opportunity to communicate and discuss issues in a less formalized decision-making structure. He noted that there are also other groups, such as the Council of Chief State School Officers, which provide forums for discussion of issues across state lines and that there are states which have no means by which to communicate across department lines. He mentioned specific examples of partnerships between agencies, state and local entities, public and private entities, and others including the family forum trips by the Governor, working with community leaders in Waterloo to address the problems of Bosnian refugees, the Health Care Reform Task Force which included both public and private input from throughout the state and which developed a consensus document, the Health Regulation Task Force which addressed the broad area of health care regulation, and the Welfare Reform Task Force which included a variety of participants to develop the implementation plan for welfare reform.

Needs of Children. Director Palmer discussed the issue of the goal of the Subcommittee in meeting the needs of children ages 0-5 and their families, without duplicating programs or using resources inefficiently. He recommended that the Subcommittee begin by deciding what the objectives are for children ages 0-5 and their families. He noted that objectives developed must be shared by all stakeholders, including all of the branches of government. Once a collaborative vision is developed across state government, this vision can be used by local communities as a basis for organization. He provided the example of the smooth transition in welfare reform, which he attributed to involving all of the stakeholders in developing consensus as to how the system should work. Once the results are defined, the funding streams that flow into achieving the results can be reviewed. He noted that in reviewing the matrix provided to the Subcommittee, some programs appear to have been implemented because they followed a funding stream or because a limited number of individuals required a particular service, rather than because the program was viewed as a means to achieve an overall objective.

State-Local Issues. Director Palmer discussed state and local roles and noted issues that must be addressed in involving communities. The issues include the issue of trust, the absence of consistent data, differing definitions across departments, the need for "up-front" time before an effort succeeds (such as decategorization projects which have taken at least a year to be at the stage of implementation), limitations caused by funding streams, and the perception of barriers even if there is no actual barrier.

Collective Vision. Director Palmer suggested that there must exist a collective vision across government as to what the critical results are that everyone wants to achieve. Then funding streams can be aligned by either blending funding streams in a pool or planning around separate funding streams if they cannot be "blended." Once the common results are established, programming follows. The question of the state and local community roles must also be answered.

5. Discussion With Panel.

Following a short luncheon break, the Subcommittee members discussed all of the following with the panel of Directors:

• Funding Streams. It was noted that the federal government is considering the increased use of the BFR system and that this might be helpful to states and local communities in blending funds to meet core functions. There are often strings attached to the funding, but instead of pooling funding, if there is a common vision, all pots of money can be brought to the table and a joint decision can be made as to expenditures.
• Accountability. Accountability at the state and local levels must be clarified. A certain "floor" that all Iowans can depend on must be maintained by all local entities so that there is some uniformity/equity while allowing for flexibility. Fiscal accountability should be placed with one entity and then planning can be a collaborative effort.
• Governance. Local communities should define their own entity of governance. Who controls the funds and makes decisions is the entity that controls. Agreements can be forged around common or core results. The state can stipulate core results and the communities can agree on some as common. Local governance could be "place-based" so that the local effort grows out of a school, community center, etc., and programs and services are provided or managed through one-stop shopping. There are many established entities which are responsible for a variety of services/programs in a community (school districts, DHS regions, Public Health regions), and these could be aligned. Community collaboration works best if what is to be accomplished is defined so that there is a common vision.
• Integration of Programs and Services. Programs and services can be integrated vertically as well as horizontally. For example, hospitals are no longer only centers for health care but for a variety of services. Examples of models that can be used at a variety of levels include the Healthy Iowans 2000 program, which was reworked to apply not only to the state but to smaller entities such as counties and cities. Applying a state model to a local area may work for public health-oriented services, but may not work with educational services since these are very locally specific.
• Educational Services. Educational services and programs are often difficult to integrate into other human services because of the history of the educational system. At one point, teachers were instructed only to teach. However, there is movement toward the school playing a greater role, since children need to achieve at a higher level in order to be employed and parents want schools to play a larger role. Incentives to collaborate across agency and service lines include requiring collaboration in order to receive early childhood education funding.
• Standards. Minimum standards for local governance can be balanced with flexibility if there is a shared common vision. Local entities must be given some authority. Standardized templates do not work in all cases.
• Accountability. Currently, there is no point of accountability at the local level for services/programs for children ages 0-5. However, if all of those who serve the age 0-5 population develop a plan for meeting the needs of this population, then, if there is a question of accountability, the plan is the basis for any evaluation. If all stakeholders come to the table and develop a plan, then each can also bring the separate funding sources and provide funding to achieve the common vision.
• Leadership. Leadership should be provided from the state level as well as technical assistance. Communities can identify their own objectives/needs and can identify their own resources. People in small communities often know each other but they may lack expertise, while people in larger communities generally do not know each other but have expertise.
• Simple Answers. Many times a particular program is viewed as being the answer to all problems and situations, but there is no simple answer.
• Families. The extended family no longer exists as it once did and many of the services/expertise provided by the earlier generation is no longer available to the new family. Therefore, the family looks outside for support.

6. State Children's Health Insurance Program (SCHIP).

Mr. Don Herman, Administrator, Medical Services Division, DHS, presented information about SCHIP. He noted that the program was created in the federal Balanced Budget Act of 1997 by adding a new Title 21 to the federal Social Security Act. The purpose of the program is to provide health care coverage to uninsured, low-income children. Iowa will receive $32.4 million annually for a state match of 25.37 percent. Funding is available for the program as of October 1, 1997, but moneys can be carried over into subsequent years if not expended during the fiscal year. The children eligible for coverage under the program are those under 19 years of age, residing in families with incomes below 200 percent of the federal poverty level, and who are not eligible for Medicaid or who are not covered under a group health plan or other health insurance. States must submit a state plan to the federal government for approval in order to receive funding. In developing the plan for the program, states have the option of expanding the Medicaid program up to 200 percent of the federal poverty level, developing a new program, or combining the two. The benefits package must be "benchmark coverage" which is the plan used by federal employees or state employees or that is provided by the largest commercial, non-Medicaid HMO plan; or a benchmark equivalent; or an existing state-based coverage applicable to only New York, Florida, and Pennsylvania; or coverage approved by the Secretary of Health and Human Services. Mr. Herman described the work of a number of groups which have worked in the past to develop a plan for health insurance coverage for the uninsured. He noted that the most recently formed group, the SCHIP Task Force, has completed its work, that recommendations will be submitted to the Governor by December 1, 1997, that the Governor will present his legislative package in January 1998, and that the overall goal is to submit a state plan by July 1, 1998, with implementation by October 1, 1998.

7. Family Support Work Group.

Director Atchison discussed the work of the Family Support Work Group which was formed to review duplication between family support programs. To date, the Work Group has developed informal recommendations, including that language be included in contracts for services which require collaboration among the various providers of these services, and that discharge planning at hospitals include a coordination of these services for a family. The Work Group determined that rather than folding all services into one program, it would be better to provide for integration of services because there is a continuum of resources and local communities vary as to the types and sources of resources available.

8. Local Forum Reports.

Eastern Iowa. The Subcommittee discussed the results of local forums. Mr. Tom Wilson noted that he and Senator Maggie Tinsman convened a forum attended by approximately 40 people. He noted that the group was excited about addressing the needs of the 0-5-year-old population, that "who is responsible for what" is a basic question, that there is a need for funding to be more family friendly, that there is an interest in providing one-stop shopping, that there is a concern that elimination of duplication might instead result in complete elimination of a program, that there is a need for better communication but there is a concern about confidentiality, that more trust must be established between the state and local communities, and that there must be more flexibility as well as accountability.

Western Iowa. Dr. James Austin reported that he and Representative Brad Hansen had held a forum and that Representative Hansen will provide minutes of the forum at a later date. He noted that the forum discussion centered around day care and the quality of care, that people had positive comments about innovation zones, that they discussed payment for services, and that there is concern about the provision of services to special needs children during the daytime hours.

9. Subcommittee Discussion of Future Plans.

Directors Palmer, Stilwill, and Atchison recommended the following steps for the Subcommittee:

• Define what the key results are for children ages 0-5.
• Determine which of the results every child age 0-5 in Iowa has a right to achieve.
• Determine the amount of resources that members would be willing to commit to achieving the results.
• Determine the time frame for achieving these results.
• Determine the role of the state and the role of the community in achieving these results.
• Determine to what degree funding streams can or should be blended and to what extent funding should be devolved to the local level.
• Establish a system of accountability.
• Establish a means of involving all branches of government.
• Provide flexibility and empowerment at the local level.
• Develop community capacity and identify leadership. The tools and capacity exist, what is lacking is the assistance in developing them.
• Implement a common intake process, database, and directory so that all agencies, etc., are aware of the needs and services provided. All that is necessary is the will to do this and a small amount of funding. There should be a way to follow an individual through the system and through their employment, etc., to know if the needs of Iowans are being met. Workers and policymakers need common information to determine success. Director Palmer noted that if policymakers define results and measures, data that fits is needed also so that policymakers can determine success and the gaps in the system. Director Stilwill noted that the education department data linkage will soon be statewide. He noted that legal issues must be resolved and a program must be designed to allow sharing of basic information, but only the information that is sensible to share, without infringing on confidentiality. Dr. Austin noted that in Sioux City there is a social team comprised of representatives of various agencies such as DHS, the Juvenile Court, the police, and others who share information. The team is defined by the school district. Through this case management approach, all necessary parties can be involved.
• Provide an endorsement of the bigger process and overall vision, such as the work of the Council on Human Investment and Innovation Zones.
• Develop an expedited process to use when barriers surface such as someone saying that something cannot be done because it is against the law.

10. Next Scheduled Meeting.

The next meeting of the Subcommittee is scheduled for November 24, 1997, in the Supreme Court Chamber. The agenda will include a discussion of a prioritization of the state policy objectives, a review of the program matrix document, and a presentation by the Office of the Auditor of State regarding auditing and evaluation of human services.

11. Materials on File With the Legislative Service Bureau.

• Council on Human Investment document and "Iowa's Foundation for Strategic Planning" document, provided by the Department of Management.
• State of Iowa Budgeting for Results Handbook, provided by the Department of Management.
• "State Government Is One Enterprise," provided by the panel of Directors.
• Enterprise Planning Work Group document, provided by the panel of Directors.
• "Collaboration Efforts of State Agencies," provided by the panel of Directors.
• State Child Health Insurance Program documents, provided by Mr. Don Herman, Department of Human Services.
• Iowa Programs for Children matrix, developed by the Legislative Fiscal Bureau.
• Evaluation Proposal Considerations document, developed by the Legislative Fiscal Bureau.
• 1990 Population Distribution of Persons 5 Years of Age and Under, developed by the Legislative Fiscal Bureau.
• Iowa Review of Family Assets document, provided by the Iowa Department of Public Health relating to family support programs.
• Background information packet, provided by the Legislative Service Bureau.

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