Human Services is Needed
The administration and delivery of health and human services in Texas is among the most complex and costly responsibilities borne by the state. Health and human services is the second largest function of Texas state government with appropriations for the 1990-91 biennium totalling $11.8 billion, or 24.9 percent, of total state appropriations.[1] While health and human services are primarily delivered by 14 separate state agencies, a total of 25 agencies are routinely involved in some aspect of service delivery.
As depicted in Figure 1, each of the 14 primary health and human services agencies is governed by a separate board, commission or council which has agency and program-specific policy-making responsibilities. Because there is no incentive for agency boards or agencies to work together, planning and policy-making often occurs in a vacuum, all too often resulting in either unnecessary duplication of services or the failure to provide needed services because one agency assumes it is the responsibility of another. Often, policy-making is reactive in nature -- responding to acute service needs in a crisis-oriented manner rather than as the result of a progressive planning process. The reactive nature of the planning and policy-making process is, for example, manifested in its failure to emphasize the need for cost-effective, prevention-based programming.
Although the focus of the review of the health and human services function has been limited to only the most pressing problems, the problems that have been identified are largely attributable to the fragmented approach that is taken in developing, administering and delivering health and human services. This fragmentation results in such well-documented agency-wide problems as a failure to maximize federal funds; a lack of consistency in rate-setting and contracting; and, a failure to coordinate services for clients, such as transportation. However, agency accountability is impeded by a lack of common program definitions, outcome measures and regional boundaries which normally would allow for cross-agency comparisons and analyses of existing and needed services.
The Texas Performance Review determined that administration and delivery of health and human services must be treated as a single, unified system. The review also determined that a single, unified health and human services delivery system should provide for the following:
* comprehensive, statewide planning and policy development;
* a continuum of care for families and individuals;
* integration of services to improve client access;
* incentives to maximize existing resources;
* effective use of management information systems;
* system-wide accountability;
* an environment that promotes teamwork and creativity; and,
* mechanisms to foster innovation at the agency and local levels.
The review also determined that the current health and human services administrative and delivery structure is simply not designed to accommodate such a system. Unless changes are made to the existing structure to provide for centralized coordination and oversight, reorganization and consolidation of existing agencies and programs, and a comprehensive approach to service delivery, any serious attempts to address service delivery impediments and to improve the effectiveness and efficiency of services and service delivery will meet with limited success. The Texas Performance Review analysis subsequently produced a system design model which includes:
* creation of a single governing board for health and human services;
* system-wide planning and budgeting;
* integration of management information;
* reorganization and consolidation of 14 agencies into six departments;
* establishment of departmental advisory boards;
* common regional administrative structures;
* coordinated regional service delivery;
* co-location of field offices;
* common intake and eligibility processes; and,
* increased use of modern technology.
The model will serve as the vehicle through which a unified health and human services delivery system can become a reality.
As Figure 2 shows, health and human services should be delivered through an administrative structure which will include a health and human services board, six departments, and comprehensive service regions. The Board of Health and Human Services will be composed of six public members who will be charged with the responsibility of overseeing and coordinating departmental operations and regional administration. The model provides for clear lines of authority and spans of control. Key model characteristics include the following:
* the Board of Health and Human Services will have complete rule-making authority and will appoint a commissioner of health and human services;
* each department will have a unique mission relative to one another;
* each department will have a nine-member advisory board which will have the authority to propose rules and will assist the commissioner in appointing departmental directors;
* services will be delivered through comprehensive health and human services regions;
* each region will have its own health and human services regional planning board which will provide a forum for local input and innovation and serve as the starting point for system-wide budget development and planning;
* regional operations and the management of residential care facilities will be overseen by a deputy com-missioner who will be appointed by the commissioner.
Within each of the three major structural levels (i.e., board, departmental and regional), there are common management control systems. These include policy development and planning, budgeting, quality control, contracting and management information. While the roles and responsibilities borne at the board, departmental and regional levels are markedly different, the systems themselves are highly interdependent and are integral to the ability of the proposed model to properly function and respond to an ever-changing environment.
Most states over the past 30 years have undergone some degree of reorganization. The basic premise of reorganization efforts has been to concentrate more power in the governor's office; consolidate similar functions along departmental lines; eliminate the administrative responsibilities of boards and commissions to reflect more of an advisory role; coordinate administrative functions; strengthen the governor's control over the budget development process; and provide state legislatures with greater agency accountability.[2] The proposed model attempts to accommodate not only this basic premise, but more importantly, such traditional organizational principles as:
* The scalar principle, which holds that the structure be arranged in a hierarchy from the chief executive at the top to the worker at the bottom, with a clear line of authority, responsibility and chain of command.[3]
* The principle of organizational balance, which holds that each portion or function of the organization should operate with equal effectiveness in making its contribution to the total purpose.[4]
* The principle of organizational simplicity, which holds that the simplest structure is the best structure.[5]
* The principle of departmentalization, which holds that groupings of both people and functions within an organization should be done according to common elements.[6]
A detailed analysis of the model is presented in the following parts of this section. Each of the three structural levels of the model is discussed separately to clearly explain level-specific fragmentation-related problems and the role that each level would play in the development and maintenance of a unified system for the administration and delivery of
health and human services. Each discussion focuses on the specific responsibilities that each level has relative to policy development and planning, budgeting, quality control, contracting, and information management. More importantly, it focuses on the level-specific tactics that are needed to achieve system-wide goals.
Because of the magnitude of change -- structural as well as cultural -- that will accompany the implementation of the model, the reorganization will need to occur in several stages. This section of the material examines some of the issues surrounding implementation, including the need for an interim transition board to develop an implementation plan for the structural model. In addition, this section discusses the fiscal implications associated with the report's recommendations.
A Single Board for Oversight and Coordination
of Health and Human Services
Should Be Created
Background
The health and human services function is the second largest function in Texas state government. The Texas Performance Review examined the operations of 14 separate agencies whose primary missions involve the delivery of health and human services through approximately 300 individual programs and activities. In addition to the 14 agencies referenced in this section, there are 11 other agencies that administer health and human services-related programs. These include, for example, the Texas Education Agency, which offers the school lunch program, and the Texas Department of Commerce, which administers job training programs under the Job Training Partnership Act (JTPA).
Each of the 14 primary health and human services agencies has its own governing structure. Each governing board, commission, or council, generally consists of gubernatorially appointed public members. With the exception of the full-time Texas Employment Commission, members are required to meet at least quarterly or at the call of the chair. As shown in Table 1, the composition of agency governing structures varies significantly.
The current structure and scope of responsibility among agency boards, commissions and councils has promoted a system of fragmentation and lack of coordination among agencies. Each agency is free-standing inasmuch as its rules and operating procedures do not have to be coordinated with those of other programs or agencies; nor is there any incentive to do so. Given that the agencies' governing bodies are predominately part-time, members have very little time to spend on the policy-making responsibilities of their own agency. The need to coordinate policy with other agencies has become secondary to maintaining funding levels and fulfilling the missions of their own agencies' programs. Most programs are agency and population-specific and do not encourage coordination. The result is that agencies have tended to work independently of one another.
The interagency coordination that does occur has developed over the years in response to the fact that state agencies are individually unable to avail themselves of the needed resources to meet ever-increasing levels of demand for services. Consequently, agencies have attempted coordination through memorandums of understanding, interagency agreements and a variety of informal methods often initiated by line employees in order to facilitate service delivery and maximize existing resources.
Nevertheless, the lack of coordination in health and human services has been a problem in Texas state government for many years. From all outward appearances, the state's health and human services delivery system operates in an uncoordinated, fragmented fashion which fosters inefficiency and ineffectiveness. Many projects and studies have attempted to develop strategies for improving the administration and delivery of health and human services. The problems identified in each of these reports are similar and typically focus on the lack of coordination among agencies, inaccessible services and the absence of a statewide comprehensive planning process for health and human services. Typically, these problems lead to recommendations calling for systemic modifications which are intended to increase coordination, accountability and oversight.
Defining the Problem. Each of Texas' 14 primary health and human services-related agencies functions independently of one another by virtue of separate governing structures. As a result, policy development does not occur in an interagency, coordinated fashion which provides for a "systems" approach to the delivery of health and human services. While interagency coordination of services does occur to a limited extent through such mechanisms as memorandums of understanding, Texas lacks a single governing structure which can provide needed system-wide coordination and oversight.
The Texas Health and Human Services Coordinating Council. In 1978, the Special Committee on Delivery of Human Services was established to examine the health and human services delivery system in Texas. The charge of the committee included examining the use of state funds, populations served and existing state and
Table 1
Health and Human Services Agency Governing Structures
Agency Governing Structure___________
Texas Department on Aging Nine-member Board
Texas Commission on Alcohol and Nine-member Commission
Drug Abuse
Texas Commission for the Blind Nine-member Commission
Texas Cancer Council 16-member Council
Texas Commission for the Deaf Nine-member Commission
Texas Employment Commission Three, full-time commissioners
Health and Human Services 21-member Council
Coordinating Council
Texas Department of Health 18-member Board
Interagency Council on Early Six-member Council
Childhood Intervention
Texas Department of Human Services Six-member Board
Juvenile Probation Commission Nine-member Commission
Texas Department of Mental Health and Nine-member Board
Mental Retardation
Texas Rehabilitation Commission Six-member Commission
Texas Youth Commission Six-member Commission
Source: Texas Performance Review.
federal laws. In addition, the committee was asked to recognize that planning is needed, to provide a means for evaluation of the system, to examine the lack of coordination, to plan for the use of all resources, and to assist in developing plans and priorities for improving the delivery of human services. After extensive deliberations, the committee issued a report in 1980, entitled Potential in the Patchwork: A Future Pattern for Human Services in Texas.[7].
The central conclusions of the Potential in the Patchwork report indicated that there was a lack of coordination, as well as the need for comprehensive policy planning and system-wide accountability. The findings subsequently led to the creation of the Health and Human Services Coordinating Council (HHSCC) in 1983 by the 68th Legislature.
The HHSCC has not been an entirely effective structure for a number of reasons. The responsibilities listed in the HHSCC's statute are permissive and not mandated by statute. This framework provided the HHSCC with no authority to perform any of its intended functions. The practical impact of the HHSCC's duties being "permissive," rather than mandated, is that the council does not have the statutory authority to require cooperation from the agencies in the health and human services system. For example, agencies continue to use their own planning process and the HHSCC does not have the power to force agencies to participate in a comprehensive planning process. In a more indirect fashion, the HHSCC's lack of authority was compounded by the fact that it is primarily funded through interagency contracts with 11 of the state's health and human services-related agencies. The agencies which the HHSCC is attempting to coordinate are also supporting its operations and projects.
The Sunset Advisory Commission conducted a review of the HHSCC and submitted a report to the 72nd Legislature in 1991. The report concluded that the current structure of the HHSCC is ineffective and that it has been unsuccessful in fulfilling its stated purpose. Specifically, the Commission staff determined that there is still no ongoing coordinated planning process for health and human services and that the charge of the HHSCC to address and coordinate on multi-agency issues has been unsuccessful.[8] Efforts at coordination often occur without the HHSCC's involvement. In addition, the Legislature assigns coordination efforts directly to the agencies involved instead of using the HHSCC as the forum for resolution. In recent legislative action, the HHSCC was abolished and an alternative coordinating body with limited powers was established in the Governor's office.
Need for Coordination Recognized. A 1988 report issued by the HHSCC included a compendium of 18 interim health and human service study groups which were to report to the 71st Legislature.[9] The creation of numerous interim study groups by the Legislature demonstrates the need for a structure that can provide a comprehensive perspective to health and human services issues. This approach would decrease the duplication of study efforts and provide a consistent approach in addressing issues that cut across agency programs.
The need for coordination in a particular area of services or with a particular service population was identified by at least 10 of the interim study groups. For example, the Long-Term Care Coordinating Council for the Elderly encouraged coordination among the Texas Department on Aging, the Texas Department of Human Services and the Texas Department of Highways and Public Transportation to provide the elderly access to services; the Legislative Task Force on AIDS concluded that there is a need to coordinate AIDS-related services; and, the Senate Select Committee on the Juvenile Justice System documented the need for greater interagency coordination in the provision of services to children and youth.[10]
The need for increased coordination is demonstrated in other forums as well. The legislative appropriation process has become increasingly complex and cumbersome when attempting to prioritize and address health and human services funding needs. Each of the 14 primary health and human services agencies develops its own budget. With such a great number of budget requests to examine, the sheer volume of facts and figures makes it difficult for the Legislature to organize service needs in a logical fashion. In fact, this disjointed approach leads to active competition among agencies for state dollars, raising the specter that some vital needs are being left unmet simply because one agency was able to make a more persuasive case than another.
Effect on the Public. The need for increased coordination is one that impacts and is of concern to the public as well. Many of the state's health and human services providers have referred to the lack of coordination and its impact on a clients' ability to access services. Interviews with staff from a variety of service areas conducted by the Texas Performance Review team have indicated that clients are continually frustrated about the complexity of accessing the services to which they may be entitled. Suggestions have generally leaned toward a system that promotes integrated eligibility at the service delivery level.
System-wide fragmentation and diffused authority can delay the establishment of needed services. For example, the Texas Department of Human Services' medical transportation program was created as a result of a federal lawsuit which concluded that many Medicaid-eligible clients were unable to receive the services to which they were entitled because they had no means of transportation. As a result, Texas now offers the transportation services for Medicaid-eligible clients. However, the delay in providing these services probably could have been avoided if there had been a centralized coordination and oversight structure that could have identified the transportation needs of Medicaid clients and planned for them accordingly.
Another problem resulting from a lack of coordination occurs in the residential care services system for children. The Health and Human Services Coordinating Council was given the task of establishing appropriate payments for residential care services for youth. This request was prompted because this service was being supported by several different state agencies at differing prices. This created a degree of competition for space instead of space being made available based on need. The result was that children who were clients of an agency paying a lower rate were considered a lesser priority for available bed space, regardless of the apparent need. Due to the lack of coordination and a centralized policy-making structure, the clients in need of services were not necessarily receiving such services.
Other State Structures: Human services in other states are delivered through a variety of administrative structures. However, a majority of states operate through a cabinet form of government which provides a structure for coordination and statewide guidance and policy development. In a state cabinet structure, department heads report directly to the governor rather than to their respective boards. In a cabinet structure, boards and commissions take on an advisory role and continue to be a forum for public input. As of 1989, 40 of the 50 states operated through a cabinet form of government. A recent survey conducted by the Wyoming Joint Reorganization Council indicated that centralized planning and policy-making responsibility provides increased coordination of state services and enables more cohesive policy development and implementation to occur, allowing the state to move toward an overall goal.[11]
While Texas cannot constitutionally move to such a centralized, cabinet approach, the creation of a single governing structure would provide needed oversight and coordination which would address many of the current fragmentation-related problems. A single health and human services board would permit the centralization of basic administrative functions, yet allow for services to be delivered in a comprehensive, decentralized fashion. As shown in Table 2, the achievement of generally-agreed upon system-wide goals would be facilitated through a Board of Health and Human Services.
The Texas Performance Review identified a number of key management control systems which are critical to the success of a single board. These include policy development and planning, budgeting, quality control, contracting, and information management . The roles that each of these play in supporting a systems approach to the adminis-tration and delivery of health and human services from a board perspective are discussed below.
Table 2
Statewide Goals for the Health and Human Service System in Texas
Relevant System-wide Goal HHS Board Implementation Tactics
Develop a comprehensive, statewide approach Develop statewide planning process includ-
to the planning of health and human services. ing strategic, budget-cycle and operational
Create a continuum of care for families planning.
and individuals. Develop a single legislative appropriations
Integrate services to provide for the efficient request for health and human services.
and timely delivery of services. Develop a quality control system that will
Maximize existing resources through better ensure efficient and effective operations.
funds management and the sharing of Develop standard contracting and rate-setting
administrative functions. procedures in order to coordinate and stream-
Effectively use management information line service delivery.
systems to improve service delivery. Develop a management information system
Provide for system-wide accountability through that provides for effective planning and de-
improved monitoring mechanisms. cision-making and efficient service delivery.
Promote teamwork among agencies and provide Establish a system of regional administration and
incentives for creativity. oversight to facilitate coordination
Foster innovation at the local level. and consistency among service delivery systems.
Source: Texas Performance Review.
Policy Development and Planning. Organizational or system planning generally occurs on three levels. Strategic planning is the broadest of these and generally is aimed at addressing the mission and direction of the system. Strategic plans are usually developed for five to 10-year periods, and should include input from the system as a whole.
The next level of planning is linked to the budget cycle. This process is more short term in nature and focuses on programmatic directions and priorities. Ideally, budget-related planning should track the strategic plan by setting priorities in terms of programmatic budget requests.
The final type of planning is operational planning. Operational planning is the day-to-day planning which addresses the more practical aspects of agency administration. This level of planning is done on a much shorter time-frame (e.g., annual, monthly, weekly). Ideally, the budget and operational planning processes should be inextricably linked to the strategic planning process so as to provide the pragmatic aspects necessary to realize the goals and directions set forth by the strategic plan.
One key component involved in planning is policy analysis and development. The ability to address issues on a system-wide basis is essential to planning for the direction of the system. Policy analysis and development have the potential of providing information on the current status of the system, which is pertinent to determining where the system should go.
Finally, the coordination and management of federal funds is a responsibility that is integrally connected to the tasks of planning and policy development. More than half of the approximately $12 billion appropriated for health and human services for the 1990-1991 biennium are federal funds. Texas has typically done a poor job of obtaining federal funds, particularly in regard to Medicaid. Due to the fragmented nature of services in the state, there has been very little incentive for agencies to collaborate in their efforts to identify available federal funding sources. Providing a statewide mechanism to maximize federal funds, track potential changes in federal funding and improve Texas receipt of federal grants, would provide the state with an enhanced opportunity to maximize funding opportunities that are currently being overlooked.
Although Texas' primary health and human services agencies develop five to 10-year strategic plans, these plans are not well-integrated into the agency operations and budget planning processes that occur in conjunction with the biennial state appropriations process. In fact most agency planning that occurs is focused on budget-related issues and employs the use of workload and immediate output rather than outcome measures. These workload and output measures are program and agency-specific and do not demonstrate inter-program or interagency relationships. Little provision is made for planning to occur on either an inter- or supra-agency basis which emphasizes the relationship of agency programs and activities to service outcomes and the achievement of goals. As a result, it is difficult to plan for and fund health and human services from a systems perspective.
The Board of Health and Human Services (BHHS) should be given the responsibility of statewide planning for the health and human services system. This role would include strategic planning and operational planning. In addition, as a part of the planning process, the BHHS should develop a methodology for allocating funds to regions. Although much of the responsibility for developing standards related to the strategic and operational plans will be vested in the departments and responsibility for implementing the strategic and operational plans will be vested with the regions, the BHHS should have the responsibility of recommending and approving plan modifications. This will ensure that the direction established by the board will remain consistent and coordinated. Table 3 summarizes the roles and responsibilities of the BHHS regarding policy planning and development.
Table 3
Policy Development and Planning Roles and Responsibilities
BHHS
* Develop statewide strategic plan and operational plans.
* Recommend/approve changes to plans.
* Develop funding allocation methodology for regions.
As a part of the planning process, the BHHS would incorporate the program-specific plans developed by the departments and the region-specific plans developed at the regional level into a statewide strategic plan. As a means of enhancing the planning process, the BHHS would be responsible for facilitating coordination on policy issues that affect and direct the planning process, in order to anticipate cross-program and department issues. Finally, the BHHS would be responsible for federal funds management including the maximization of federal funds, tracking changes in federal funding and developing and managing federal grants.
Budgeting. Each of the 14 health and human services agencies develops its own budget requests independently. There is no mechanism for coordinating, prioritizing or consolidating funding requests across agencies. The current legislative appropriation request (LAR) process requires agencies to prioritize their programs and spending requests. In turn, the Legislative Budget Board (LBB) and the Legislature use the LARs to make decisions about individual programs. The LBB, however, does not have the staff resources or authority to prioritize and coordinate programs across agencies.
The BHHS should be given the responsibility of developing a single LAR for health and human services. The budget process should be closely linked to the planning process in that the development of a single consolidated LAR for various departments would include the tactics and strategies needed to achieve the goals, objectives and desired outcomes set forth in the strategic plan. The BHHS would also be responsible for determining: 1) regional budget execution authority; and 2) including income-based performance measures in the budget.
Quality Control. Quality control is the system by which an organization evaluates the success of its planning process and the system as a whole. The basic process of quality control involves some standard steps, including: (1) setting performance standards; (2) measuring the performance; (3) evaluating the performance; and (4) making effective use of feedback and taking corrective action when necessary. A system that provides quality control should not only ensure that the proper controls are in place to produce the desired outcomes, but also that the desired outcomes are actually being realized. Ideally, the budgeting process and the strategic planning process should be closely linked. Therefore, the quality control mechanisms established by the BHHS should provide both fiscal and service delivery accountability, based on expectations established through the budgeting and planning processes.
A system-wide quality control function should be established by the BHHS which would be overseen by an Office of the Inspector General. This office would be responsible for ensuring that the BHHS statewide plans are being properly implemented, that departmental programs are being efficiently and effectively operated and that services are being delivered according to relevant standards. The office would coordinate BHHS and departmental auditing and monitoring plans, receive all quality control reports and ensure that timely corrective action is taken. The BHHS would also approve departmental quality control standards. Specific BBHS roles and responsibilities as they relate to quality control are shown in Table 4.
Table 4
Quality Control Roles and Responsibilities
BHHS
* Appoints Inspector General.
* Develops administrative standards.
* Approves regional quality control plan.
* Approves departmental program quality standards.
* Coordinates board and departmental quality control procedures.
* Receives departmental audit and monitoring reports.
* Ensures that timely corrective action is taken in response to audit findings.
Contracting. Contracting in health and human services is a process by which an agreement is entered into for the provision of services. For example, instead of an agency providing services directly, the agency may choose to contract with a community nonprofit organization to provide needed services. Agencies use a variety of contracting methods to deliver services. The State Purchasing and General Services Commission has a set of rules and statutes that generically govern the practice of contracting. Agencies also comply with procedures set forth in the Uniform Grant and Contract Management Act of 1981. In addition, most agencies have also developed more detailed rules that govern their contracting practices. Agencies and service providers are required to maintain compliance with voluminous rules which are not coordinated or streamlined in any fashion. The roles and responsibilities that the BHHS would have relative to contracting are summarized in Table 5.
Table 5
Contracting Roles and Responsibilities
BHHS
* Develop standards governing when and how contracting should occur.
* Develop processes which govern all phases of contracting from acquisition
to compliance monitoring.
* Set administrative contracting, performance and monitoring standards.
* Rate-setting
The role of the BHHS will be to provide guidelines and standards governing the contracting practices of health and human services. The process established by the BHHS should ensure that state funds are spent efficiently and effectively and in a manner designed to meet the board's goals and objectives.
The BHHS should ensure that contracted services are properly planned, acquired, monitored and evaluated. To do this, a systemwide contracting function should be established by the BHHS. This function should develop policies and procedures which control the acquisition phase of contracting. Standards should also be developed which govern the monitoring and noncompliance resolution processes. An additional responsibility of the BHHS will be to serve as the final decision point on rate-setting discussions. However, the BHHS would have the authority to delegate this role as it deems appropriate.
Information Management. A management information system (MIS) provides the network of information necessary to facilitate effective planning, controlling and decision-making. An MIS should provide feedback on system performance in terms of how well a unit of operation has met the goals established through the planning process. An effective MIS should also draw attention to any problems or inconsistencies. Finally, an MIS system should provide the basis for research and planning. Data gathered from the system should be able to provide the information necessary to plan for future goals and strategies of the system. Currently, management information in Texas' 14 health and human services is administered via five separate, nonlinked mainframe systems. In addition, there are five agencies that have little or no on-line computer capability. This fragmented information system is a key factor that prohibits successful planning and policy development. The roles and responsibilities of the BHHS relative to information management are shown in Table 6.
Table 6
Information Management Roles And Responsibilities
BHHS
* Input administrative information as well as personnel, payroll, inventory and procure-ment information.
* Develop, coordinate and integrate statewide service system.
* Generate information for use by the board, departments and regions, in planning, decision-making and evaluation.
An MIS should be developed and operated as a component of the board. The system should be established in a way that provides performance feedback on each component of the system. This should provide the BHHS, the departments and the regions with the tools necessary to facilitate effective planning, performance and evaluation. The system should also be used to develop, coordinate and integrate a statewide service delivery system which would include the creation and maintenance of a central client and services database and an integrated eligibility system.
Regional Administration and Oversight. Health and human services are administered and delivered through various mechanisms. Delivery systems involve direct delivery of services through regions, state facilities and local providers, or through a combination of these options. At least six of the 14 primary health and human service agencies have a regional service delivery structure in place. The role of the BHHS should be one that facilitates coordination, mediates policy disputes and promotes communication among the whole system. Specific BHHS roles and responsibilities relating to regional administration and oversight are shown in Table 7.
Table 7
Regional Administration and Oversight
Roles and Responsibilities
BHHS
* Ensure that programs are efficiently and effectively operated.
* Participate and approve regional plans.
* Ensure regional plans are implemented and goals are met.
* Ensure timely corrective action is taken to remedy deficiencies.
* Coordinate and approve the development of regional budgets.
* Mediate between departments and regions.
* Communicate the board's values and goals to the regions.
Responsibility for both regional oversight and management of the state's residential care facilities will be vested with a deputy commissioner who is appointed by the Commissioner of Health and Human Services. The deputy commissioner will, in turn, have two assistant deputy commissioners. One will be responsible for regional opera-tions while the other is responsible for facilities management. The deputy commissioner would be responsible for appointing regional administrators.
Recommended Policy
A board should be established which has the statutory authority, staff and funding to provide for the oversight and coordination of the state's health and human services-related departments and programs. At a minimum, this board would be vested with the following system-wide responsibilities:
* Policy Development and Planning
* Budgeting
* Quality Control
* Contracting
* Information Management
* Regional Administration and Oversight
The membership of the Board of Health and Human Services should include six guberna-torially appointed public members who serve on a part-time basis for staggered six year terms. The board would hire a commissioner of health and human services who would oversee departmental and regional operations.
A six-member governing board should provide continuity and broad geographic representation. In addition, a six member board will provide philosophical diversity, public access to members, division of workload and the potential for expertise in given areas of service delivery.
The review also determined that the governing board should have public membership, with no slotted positions for special interests or client populations. Enabling statutes for health and human services agencies usually recommend that appointees have a demonstrated interest in the particular area or population they are serving. The proposed Board of Health and Human Services is intended to provide a comprehensive perspective to an increasingly complex array of health and human services. With the vast diversity of services and populations served in the health and human services arena, it would be impossible to accommodate all special populations or interests by designating slotted positions. Requiring that the board members have a broadly demonstrated interest in health and human services will ensure the maintenance of the overall perspective necessary to design, execute and monitor health and human services in a fashion that serves the broadest and most diverse population needs.
The Agencies Providing Health and Human Services
Should Be Reorganized and Consolidated
Background
Based on a comparison of other states conducted by Texas Performance Review staff, Texas has one of the largest numbers of state agencies providing health and human services. In addition to 14 separate agencies whose primary missions involve service delivery, there are 11 other state agencies which also provide health and human services. The 14 primary agencies oversee approximately 300 individual programs and activities through which services are delivered.
Virtually all of the agencies and many of the individual programs and activities are self-contained. They each have their own rules, regulations, forms, reporting requirements, terminology and service definitions, accounting procedures, administrative hierarchies, client populations and service delivery systems. The result is a morass of agencies, programs and services with rigid management structures, which precludes needed interagency and inter-program coordination and collaboration in order to provide for the efficient and effective delivery of services. In fact, Texas' health and human services function today can be characterized as the Brownlow Committee characterized the executive branch of the federal government in 1939 in its recommendation to consolidate and rationalize an executive branch that had "...grown up without plan or design like the barn, shacks, silos, tool sheds and garages of an old farm."[12]
The fragmentation which exists in the administration and delivery of health and human services in Texas results not only in added costs to the state, but to clients in need of services. Clients often have multiple needs and thus are often required to access a different agency or program for each of their problems. Eligibility requirements vary among agencies and programs and only add to a client's frustrations about the lack of a systems approach to health and human services.
Because each agency assesses needs, collects data, determines priorities and delivers services independently, full accountability of state funds invested in health and human services by the State of Texas is difficult to achieve. The lack of common definitions for programs, outcomes and geographical areas limits the scope of cross-agency and cross-program comparisons--thereby impeding a comprehensive, function-wide analysis of health and human services which could more readily identify duplications and gaps in service.
To address some of the problems which are inextricably linked to how health and human services are currently administered in Texas, the Texas Performance Review staff concluded that the reorganization and consolidation of 14 agencies into six departments is a requisite first step. Reorganization in and of itself will not solve many of the problems which affect those needing to avail themselves of health and human services. However, reorganization is an integral step in the development of a single, unified service delivery system which will provide for the achievement of such goals as a "continuum of care" for families and individuals and the integration of services. Table 8 provides a list of system-wide goals and the department-level tactics needed to achieve them.
Research indicates that efficiencies can be gained by focusing departments on particular populations or functions as opposed to funding sources. No matter how services and programs are organized, some interrelationships will exist regarding clients served, since many of the people needing services need multiple services. For example, a person who is unemployed and requests employment services may also need income assistance, health services and vocational training. The following principles have been established to guide this review:
* reorganization efforts should focus on the people who need services -- rather than the funding source or established bureaucracy;
* reorganization should promote a continuum of service -- the dollars should follow the client, rather than the client having to search for appropriate services; and
* any cost savings from reorganization should be used to provide additional services.
Table 8
Department-Level Tactics for Implementing System-Wide Goals
System-Wide Goals Departmental Implementation Tactics
Develop a comprehensive, statewide Recommend plans for the department to the
approach to the planning of health and board.
human services. Propose policy, rules and regulations to
Create a continuum of care for families be adopted.
by the board. Provide an array of services which can be accessed
Integrate services to provide for the by a family or individual which will provide an
efficient and timely delivery of services. appropriate level of service.
Maximize existing resources through Departments will be organized to focus on the
better funds management and the sharing client and have the funding follow the client.
of administrative functions. Propose operating procedures for programs.
Effectively use management information Propose a department budget which will flow into
systems to improve service delivery. the statewide budget process.
Provide for system-wide accountability Provide information into a central system which
through improved monitoring mechanisms. will be available to all departments and regions;
Promote teamwork among agencies and client and program data will be included.
provide incentives for creativity. Develop and implement systems for monitoring
Foster innovation at the local level. whether programs are appropriate and being
delivered efficiently.
Communicate and coordinate across department lines, constantly striving for better methods
and outcomes.
Solicit input from regions and local communities; spearhead pilot projects.
Source: Texas Performance Review.
Reorganization Plan. Just as there is no single "correct" way to organize health and human services at the agency level, there is also no single correct grouping of programs within each department. A review of the 10 most populous states found that a variety of program groupings are currently being used. Given the diversity of Texas' client populations, geography and level of economic development, a case could be made for different department groupings for each geographic region of the state. To compensate for these deficiencies, other states have realized that technology can be used to make the system "seamless." For example, integrated eligibility can make case management possible, which can provide clients with a guide through the health and human services system while assuring that state resources are being used efficiently and effectively.
The regrouping attempts to better focus departmental operations or like functions as well as client populations. The groupings presented represent a mixture of functional and client-based approaches. The overall intent is to provide, in a more comprehensive and integrated management setting, department structures that allow managers to focus their efforts on developing service and budget strategies that provide for the most effective use of available funding and service techniques. For example, the proposed community and residential care department combines a variety of programs, now in five separate agencies, that use state and federal funding sources to provide a spectrum of services ranging from in-home to institution-based care. Combining these program approaches will enable department managers to think comprehensively about the clients being served by these programs and develop integrated strategies to make the most of funding sources and innovative program delivery techniques. Due to the disparate nature of program operations, this cross-generation of ideas and ability to focus on the needs of certain kinds of clients cannot easily occur. The review attempted to combine programs in a manner that allows a more comprehensive approach to managing services and client populations than is possible under the current system.
Based upon an analysis conducted by Texas Performance Review staff, the following groupings are proposed. In a few cases, entire existing agencies are collapsed into a new department. In most cases, however, programs and activities in existing agencies are divided among two or more new agencies. Detail is provided at the program and activity level as necessary to clarify the program or activity to be transferred. Ultimately, the number of programs and activities should decrease as Texas moves away from condition-specific programs to a continuum of health and human services. The six departments are discussed in the following sections.
Health Services. The goal in establishing a health services department is to provide a continuum of health care to the medically needy citizens of Texas. It also provides for the combination of the state's major funding options for preventive and acute health care. In this vein, this department will focus on public health issues, emphasizing disease prevention and health promotion.
The concept of public health presented here relates to both physical and environmental health. This department will have responsibility for assessing the health needs based on statewide data collection, making recommendations to the policy board on health policy by identifying essential health services, ensuring an adequate health service delivery system, and promoting local service capacity to deliver services. Table 9 lists the current programs and activities which would be included in the new Department of Health Services.
Table 9
Department of Health Services
Programs and Activities
Health Services
Preventive Health Services Preventive Health Services Continued:
Interagency Council on Early Childhood Intervention - Texas Department of Mental Health and Mental
All programs Retardation
Texas Commission on Alcohol and Drug Abuse - Genetics Screening and Counseling Program
All programs Chronic Disease Prevention and Control Activity
Texas Cancer Council - All programs Primary Care Activity
Texas Department of Human Services - Preventive Dental Health Activity
Services Programs Texas Diabetes Council Activity
Early, Periodic Screening, and Diagnosis and
Treatment Acute Care Services
Family Planning San Antonio State Chest Hospital - All programs
Texas Department of Health -- South Texas Hospital - All programs
Community and Rural Health Program Texas Department of Health --
Disease Prevention Program Chronically Ill and Disabled Children Activity
Vital Statistics Activity Children's Outreach Heart Activity
Milk and Dairy Activity Kidney Health Care Activity
Food and Drug Activity Adult Hemophilia Activity
Shellfish Sanitation Activity Texas Department of Human Services -
Zoonosis Control Activity Purchased Health Services Program
Cooperative Meat Inspection Activity Indigent Health Care Program
General Sanitation Activity Texas Rehabilitation Commission -Comprehensive
Maternal and Child Health Activity Medical Rehabilitation Activity
Women, Infants and Children Activity
Epilepsy Activity
Source: Texas Performance Review.
All health-related functions should be placed in this department. These include disease prevention, health promotion, all Medicaid-related preventive services and other indigent health care activities, alcohol and substance abuse and environmental activities clearly requiring health expertise. More emphasis should be placed on preventive programs. Treating illness is much more expensive than providing preventive-based services. Two examples are:
* Prenatal care is effective in preventing critical situations with low-weight babies which require neonatal care. Prenatal care is far less expensive than neonatal care.
* Education and treatment for high blood pressure and diabetes can prevent end-stage kidney disease which requires dialysis or organ transplant. The cost of dialyses and organ transplants far exceeds the cost of education and treatment for high blood pressure and diabetes.
The Department of Health Services should have two major service divisions: preventive health and acute care. Although the distinction between prevention and acute care is not absolute, acute care programs are designed to treat existing illnesses or conditions, in general, and preventive programs have a primary mission to prevent illness or a condition from occurring.
Providing a continuum of health care will help to eliminate overlap and duplication of services. It will also allow comprehensive planning for the health care needs of Texans. For example, securing health care for children can often be complicated and confusing. Children's health care is provided through a number of programs including the Medicaid, Early Childhood Intervention and the Chronically Ill and Disabled Children's programs. The eligibility criteria for each of these programs vary, and it is often difficult to determine which program is appropriate for a parti-cular situation. Moving all of these programs under the same administrative structure will provide a better forum for resolving any conflict or overlap in eligibility and service standards.
The environmental programs, water hygiene, industrial hygiene, radiation control and solid waste, currently administered by the Texas Department of Health, should be transferred to the proposed Department of the Environment. This issue is discussed in the Natural Resources section of this report.
Family Services. The goal in combining the following list of programs is to consolidate those services whose focus is on saving at-risk families and to provide a continuum of care for parents and children. These are services whose common goal is to promote self-sufficiency and foster independence. This would be the "social services" department. These services include financial assistance such as Aid to Families with Dependent Children (AFDC) and food stamps, housing assistance and day care. Other services will be specifically focused on children at risk of physical and emotional abuse. Services will include foster care, family counseling, parenting classes and services for youth offenders. Table 10 depicts the programs and activities that will be included in the new family services department.
The Department of Family Services would provide social services needed in situations of child abuse and neglect, but would not be responsible for the investigation function. The investigation function would be conducted by the proposed protective services and regulatory department. This structure also provides a social service orientation in the treatment of delinquent children, and should enhance the work done by the juvenile courts.
Although prevention is not commonly associated with social services, it is recommended that the Department of Family Services should focus on prevention rather than just responding to crises. This approach to social service may be effective in averting problems associated with teen pregnancy, substance abuse and family violence. A focus on prevention may require increased staff or some shifting of program priorities to more early identification, education and training, targeting the at-risk populations.
In promoting the idea of prevention, the Children's Trust Fund should be included in this department. This program had been administered by the Texas Department of Human Services until May 1991, when legislation was passed to create a separate department, the Children's Trust Fund of Texas Council. The purpose of the Council is to fund programs for the prevention of child abuse and neglect. Creating more health and human service agencies is in conflict with the current goal of being more comprehensive and efficient. Because of the goal to have fewer agencies and to promote a "continuum of care," this transfer makes sense.
Protective and Regulatory Services. The goal of creating the protective and regulatory services department is to allow for the separation of the investigative and social services aspects of child and adult abuse cases. Separating the investigative function from the social service function should strengthen each function.
Table 10
Department of Family Services
Programs and Activities
Family Services
Juvenile Probation Commission All programs
Texas Youth Commission All programs
Texas Department of Human Services Children's Trust Fund Program[13]
Client Self-Support Services Program
- AFDC
- Food Stamps
- Energy Services
- Employment Services
- Child Day Care Services
- Refugee Services
- Emergency Nutrition and Emergency Relief
Services
- Disaster Assistance
- Nutrition Assistance
Child Protective Services: In-Home Services
Activity
Child Protective Services Program: Purchased
Services Activity
Foster and Residential Care Payments Activity
Adoption Support Payments Activity
Alternate Treatment for Youth Activity
Family Violence Services Activity
Services for Runaway and At-Risk Youth Activity
Source: Texas Performance Review.
Traditionally, the mission of the social worker is to rehabilitate and preserve the family whenever possible. On the other hand, the mission of an investigator in a report of abuse is to investigate the case to determine if the alleged abuse occurred and to remove the victim from the situation if necessary. Separating the investigative aspects of this activity will also allow for more focused staff training and the development of consistent procedures to carry out investigation of alleged harm or abuse perpetrated against those who cannot protect themselves. This includes chil-dren, disabled or aged adults and persons in state institutions. Separating these functions from these social service programs will also solve a long-standing problem related to agencies being in a position to investigate themselves. For example, this is an issue faced by the Texas Department of Mental Health and Mental Retardation (TDMHMR) which investigates cases of alleged abuse in its own institutional facilities. TDMHMR's lack of "arm's-length" ob-jectivity will always call the propriety of this situation into question.
Separating investigation and support is not a simple programmatic transfer, as many of the activities are currently performed by the same departments. In fact, this separation may appear to contradict the effort to consolidate similar functions. However, the review indicated that the two functions deserve focused and separate attention. Maintaining the functions in the same agency makes the responsibility of providing social services to a family in need and investigating a report of abuse a nearly impossible situation in which to maintain objectivity and focus.
The major responsibilities of this department would be to investigate allegations of child abuse, adult abuse and institutional abuse and to take appropriate action. The emphasis would be on providing maximum protection to the abused. This may require that the alleged victim be removed from the environment creating the threat. Cases could then be referred to social workers in the Department of Family Services so that the appropriate social services can be provided. Ongoing interaction with the Department will be necessary because many cases will be referred to social workers. Table 11 shows the services that will be included in the protective and regulatory services department.
Table 11
Department of Protective and Regulatory Services
Programs and Activities
Protective and Regulatory Services
Office of the Attorney General Youth Care Investigation Activity
Texas Department of Health Long Term Care Activity
Licensing and Certification Activity
Institutional Component
Texas Department of Human Services Adult Protective Services Program
Child Protective Services Program:
Investigations Activity
Licensing of Child Care Facilities Activity
To further strengthen the investigative function for protecting children, the Youth Care Investigation activity, currently administered by the Office of the Attorney General, should be transferred to the Department of Protective and Regulatory Services. This program is responsible for investigating reports of child abuse where a state agency has custody of the child.
This department will also assume the state's regulatory responsibilities concerning nursing homes, hospitals and child care facilities. These functions, which involve similar inspection and enforcement activities, are now split between the Texas Department of Health and the Texas Department of Human Services. Consolidation of these functions in the Department of Protective and Regulatory Services will allow this one state entity to develop comprehensive staff training and enforcement efforts to protect citizens of all ages from harm that can be perpetrated by those entrusted with their care.
Workforce Development. The grouping represented here assembles programs whose common function is to provide comprehensive employment services to the economically disadvantaged or unemployed population of the state. With the exception of the AFDC-related Jobs Opportunity and Basic Skills (JOBS) program, currently administered through the Texas Department of Human Services, this grouping will draw together all the state's employment-related services that are not targeted at a special population requiring special training. This grouping thus excludes training programs for special populations such as physically or mentally-disabled persons or hearing-impaired and visually-impaired persons.
The issue of consolidating workforce development issues has been a long-standing concern. A review was conducted to determine other states' location of employment services. The Interstate Conference of Employment Security Administrators (ICESA) identified 37 states where Employment Services (ES), Job Training and Partnership Act (JTPA) programs and Unemployment Insurance (UI) programs were administratively located in a single state agency. A further study conducted by the Lyndon Baines Johnson School of Public Affair's Center for the Study of Human Resources found that almost 80 percent of the states have these three programs consolidated into a single state agency. In addition, the survey also identified six states in which the three programs are combined under a single state agency umbrella and which have attempted to consolidate the ES and JTPA management functions and staff.
The proposed workforce development department would administer the Texas Unemployment Compensation Act and would be responsible for the employment insurance program which includes collecting payroll taxes from employers in the state subject to the terms of the Act. Other responsibilities include paying unemployment benefits to eligible applicants, providing free employment services and providing employment training programs. Table 12 lists the component programs and activities of the Department of Workforce Development.
Table 12
Department of Workforce Development
Programs and Activities
Workforce Development Services
Texas Employment Commission All programs
Texas Department on Aging Senior Texans Employment Program
Texas Department of Commerce Job Training Partnership Act Program
Source: Texas Performance Review.
The Senior Texans' Employment Program (STEP), which has been administered by the Texas Department on Aging, should be transferred to the Department of Workforce Development. The Department on Aging currently contracts with an organization which works with over 300 non-profit organizations, and state and municipal agencies for the training of older workers. The STEP program focuses on the placement of older workers in rural communities. Examples of services provided by this program include museum renovation, courthouse improvement, and park beautification. In addition, STEP workers are placed in some of the following types of agencies: senior nutrition projects; public transportation services; probation offices; information and referral services, libraries, schools and state agencies.[14]
The inclusion of workforce development-related programs and services in the health and human services function is needed. Based on a computer match of social security numbers done in conjunction with the Texas Performance Review, more than 400,000 Texans receive services from both TEC and TDHS. Many clients who are participating in employment programs are either in need of temporary nonemployment-related services in order to attain self-sufficiency, or may eventually be in need of such services. Integrating workforce development programs with other health and human services-related programs and services will provide more of a systems approach to serving client needs.
Rehabilitative Services. The goal of this combination is to provide for a comprehensive approach to vocational rehabilitation services for populations in need of special training, allowing as many clients as possible to enter or return to the workforce. This includes physically or mentally disabled, hearing impaired and visually impaired persons. Currently, these services are administered by three separate agencies: the Texas Rehabilitation Commission (TRC), the Texas Commission for the Blind (TCB) and the Texas Commission for the Deaf. Both TRC and TCB currently receive federal vocational rehabilitation funds. In the past, TCB has had difficulty raising its share of the state match whereas TRC generally has had adequate state funds to draw down their share of federal funds. Combining these agencies under a single administrative structure would ease the task of generating the state match needed to draw down federal vocational rehabilitation funds.
Including deaf-related services in a rehabilitation focused setting has been a topic of discussion for many years. If reorganization of Health and Human Services agencies occurs, the best "fit" for the types of services provided by the Texas Commission for the Deaf (TCD) would be with the TRC and the TCB.
The services provided by the three agencies are similar in that they are geared toward fostering independence and re-integration into the community and workforce.
The major responsibilities of the rehabilitation department would be physical, mental and vocational rehabilitation. The physical, mental and vocational rehabilitation services provided by the TRC, the TCB and the TCD should be combined to create a Department of Rehabilitation Services. A single department would be better able to coordinate rehabilitation services and use state dollars more efficiently for the dual purposes of state match and maintenance-of-effort. Clients with multiple disabilities can be served more efficiently and effectively. Table 13 lists the programs and activities that will be combined.
Table 13
Department of Rehabilitative Services
Programs and Activities
Rehabilitative Services
Texas Commission for the Deaf All programs
Texas Commission for the Blind Rehabilitation Services Program
Blind and Visually Impaired Children Activity
Texas Rehabilitation Commission Vocational Rehabilitation Services Program
Transitional Services Program
Disability Determination Program
Community Integrated Employment Activity
Alternative Sheltered Employment Activity
Supported Employment Activity
Developmental Disabilities Services Activity
Council on Disabilities Activity
Community and Residential Care. The common goal of the programs included in this grouping is to facilitate a degree of independence to the extent possible for aged and disabled persons. The services for the most part, tend to be long-term in nature. This department will have two major divisions: community services and residential services.
Community Services. This division includes those services which help aged and disabled remain independent and living in the community. These include: in-home services, community services and independent living services which are now provided in the Texas Department of Human Services, Texas Department of Mental Health and Mental Retardation, the Texas Department on Aging, the Commisison for the Blind and the Rehabilitation Commission. Specific activities include transportation, home-delivered meals, homemaker services, personal attendant services, architectural modification or equipment, emergency response systems, medical services, respite care and psychological services. Table 14 lists the programs and activities of the community and residential care department.
This department will have responsibility for the administration of the Older Americans Act. The federal law requires that the services provided with these Title III funds must be administered through area agencies on aging (AAAs). AAAs have the responsibility of developing and administering a coordinated and comprehensive service system for meeting the priority needs of persons 60 years and older.
Residential Services. These programs, as the table shows, are long-term care, currently provided by TDMHMR state schools, hospitals, and centers and state hospitals, and long-term nursing home services provided through TDHS' Long Term Care program. These settings will continue to provide a comprehensive array of services for those aged and disabled persons who are unable to live independently in the community.
Table 14
Department of Community and Residential Care
Programs and Activities
Community and Residential Services
Community-Based Services Community-Based Services Continued:
Texas Department on Aging Texas Rehabilitation Commission
All activities except Senior Texans Employment Independent Living Services Program
Texas Department of Human Services - Deaf/Blind Multi-handicapped Program
Community Care Services Program Personal Attendant Services Activity
In-Home and Family Support Services Activity Texas Commission for the Blind
of the Services for the Developmentally Independent Living Rehabilitation Activity
Disabled Program
Client-Care Services (Community) Residential Services
Texas Department of Mental Health and Mental Retardation Texas Department of Human Services
Community Services Activity of the State Hospitals Long Term Care Program
Schools, Centers and Programs Intermediate Care Programs
Harris County Psychiatric Center Program Client-Care Services (Residential)
Contracted Community Services Program Texas Department of Mental Health and Department of Criminal Justice Support Program Mental Retardation
In-Home and Family Support Program State Hospitals, Schools and Centers,
Mentally Ill Deaf Persons Program Campus-based Residential
Autism Services Program OBRA-PASARR Services Program
Medical Screening and Treatment Program
Recreation and Rehabilitation Center Program
Source: Texas Performance Review.
Transfer of Other Health and Human Service Programs. Environmental health activities at the Texas Department of Health would transfer to the proposed Department of the Environment. These include water hygiene, industrial hygiene, radiation control, and solid waste.
Professional licensing and certification functions would transfer to the newly-expanded Texas Department of Licensing and Regulation. These include: the Texas Department of Human Services' certification of social workers program; the Texas Rehabilitation Commission's occupational therapy licensure activity; and, the Texas Department of Health's activities related to regulation of massage therapists, respiratory care practitioners, medical radiological technicians, professional counselors, dieticians, speech pathologists and audiologists, nursing home medication aides, home health medication aides, athletic trainers, nurse aides, opticians and medical laboratory technicians.
The transfer of these programs to other agencies and the implications of such action is discussed in detail in other sections of this report.
Department Boards. Roles and responsibilities of departments' boards and commissioners will change with the shift to statewide planning and the creation of a Board of Health and Human Services.
Each department should have a nine-member advisory board appointed by the Governor. Responsibilities of the advisory boards would include:
* proposing policy, rules, and regulations for possible consideration and adoption by the Board of Health and Human Services (BHHS);
* proposing operating procedures related to program-specific implementation;
* making recommendations to the commissioner for hiring/firing the department director; and
* receiving and commenting on the proposed departmental budget prior to its submission to the BHHS.
All current agencies except for the Texas Employment Commission (TEC) have part-time boards. These boards will no longer have decision-making authority over policy, rules and regulations, but they will have advisory powers on these issues.
TEC has three full-time commissioners -- one representing labor, one representing industry, and one representing the public. The Commissioners have the responsibility of policy development for the agency and for being the final agency arbiter of appeals of denied unemployment insurance claims. Any further appeals must go to the court system. The advisory board that would be appointed to oversee the Department of Workforce Development would have nine members -- three representatives each of labor, industry and the general public. Because of the judicial function associated with the current Texas Employment Commission in the appeal process, three board members --one from each category of representation -- would be designated by the Governor to serve on an appellate committee to hear appeals. These three members would serve on a full-time, paid basis, and would also work with the other six part-time members of the advisory board in overseeing the activities of the Department of Workforce Development.
Department Directors and Staff. Each department director will be hired by and report to the Commissioner of Health and Human Services. The department director and other agency personnel will not have direct authority over program activity in the region. The departmental director will be responsible for:
* providing services as a program consultant or advisor to the regions in developing and implementing programs including day-to-day technical advice;
* developing program-related policy, rules, regulations and standards for service delivery and contracting;
* developing training curricula and competency-based standards;
* coordinating with the BHHS; developing and implementing systems for monitoring the program perfor-mance;
* providing assurance that services are appropriate and being delivered efficiently;
* providing information and expertise on service standards and rate-setting to the BHHS;
* proposing a budget for the department which will feed into the statewide budget process; and
* handling disciplinary proceedings for entities regulated by the departments.
The departments' responsibilities for key management control systems including planning, budgeting, contracting, quality assurance, and information management should shift in focus from being agency-specific to statewide. Departments will serve as the health and human services programmatic link to other states, the academic community, professional organizations, and the federal government. Departments will also serve as the repositories for information and will be the health and human service system "experts." In this role, the departments will generate ideas, suggestions and will participate in projects to position Texas' health and human services system for the future.
Additional information on these responsibilities as they relate to key management control systems is provided below.
Policy Development and Planning. Departments play a major role in programmatic policy development with specific responsibility for maintaining contact with professional groups, other states and the federal government. Other key functions include: (1) developing and proposing modifications as necessary to standards and performance measures; and (2) providing information for policy development by the BHHS. Table 15 shows the role of the departments in policy development and planning.
Table 15
Policy Development and Planning Roles
and Responsibilities
Departments * Recommend department plans to be incorporated into the state-wide plan.
* Provide input into regional planning process.
* Develop service delivery policy, rules, regulations and
standards for specific programs.
BHHS * Develop statewide plan -- both strategic, budget cycle
and operational.
* Develop methodology for resource allocation to regions.
* Recommend/approve changes to plan.
Department planning occurs at two levels: (1) preparation of the department's own plan; and (2) input into the statewide and regional planning processes. Departmental and program-specific advisory committee input into the statewide planning process --strategic, budget cycle and operational -- should reflect the goals and objectives of the department. Input into the regional process will address planned service delivery in relation to program standards.
As a result of the reorganization, the Governor's Council on Health and Human Services will be eliminated and the Board of Health and Human Services will assume its responsibilities. The Interim Transition Board for Health and Human Services discussed later in this section will determine which planning-related bodies will be elevated to the BHHS to provide input into the statewide planning process. These bodies would include, for example, the Statewide Health Coordinating Council, the Governor's Committee for Disabled Persons, the Planning Council for Developmental Disabilities and the Interagency Council for Early Childhood Intervention.
Budgeting. Departments prepare budgets for departmental operations and provide input into the regional and statewide budget processes. Department service delivery standards impact the budget staffing and rate setting decisions for direct delivery and for contracting. Table 16 shows the departments' role in the budgeting process.
Table 16
Budgeting Roles and Responsibilities
Departments * Propose a department budget which will feed into
the statewide budget process.
* Provide input into the regional budgeting process.
* Make recommendations for programmatic component
of statewide budget.
BHHS * Develop statewide budget.
* Determine regional budget execution authority.
* Include outcome-based performance measures in budget.
Departments would routinely monitor "environmental" changes which could have budgetary implications.
Quality Control. Departments develop standards for service delivery based on federal, state, and professional guidelines. Standards development includes identifying related outcome-based performance measures. Identical standards are applicable for direct and contracted delivery of services, but the contract process may require additional information. Regional quality control systems perform the first level of monitoring -- the day-to-day, as well as cyclical, monitoring of service delivery activities. Table 17 details the departments' role in quality control.
Table 17
Quality Control Roles and Responsibilities
Departments * Develop standards for both service delivery and contracting.
* Input into regional quality control plan.
* Participate in second level of quality control as coordinated
through the BHHS.
BHHS * Approve regional quality control plan.
* Coordinate second level of quality control focusing on
evaluating regional audit quality and additional
procedures as necessary.
* Take action as necessary on regional quality control reports.
Contracting. Departments are responsible for developing programmatic standards and outcome-based performance measures for: (1) inclusion in the actual contract; and (2) performance monitoring -- both during and at the end of the contract period. Departments are also responsible for both passing on information learned in their "think tank" function and using the information to develop new service delivery options. Table 18 shows the departments' role in contracting.
Table 18
Contracting Roles and Responsibilities
Departments * Develop program contract standards.
* Advise the BHHS on rate-setting.
BHHS * Set administrative contracting, performance, and monitoring
standards.
* Rate-setting
Information Management. Departments collect and maintain two types of information: information relating to departmental programs that is externally produced (e.g., other states; academia; professional organizations) and program-specific information (e.g., performance and workload measures; unmet need). These two types of information are routinely used for such purposes as program evaluation; forecasting; the initiation of pilot projects; and the development of program standards. Table 19 shows the departments' roles and responsibilities as they relate to information management.
Table 19
Information Management Roles and Responsibilities
Departments * Input program related information as well as personnel,
payroll, inventory, and procurement information.
* Provide evaluative information from other states, academia and
professional organizations.
* Supply relevant information into forecasting etc.
HHS Board * Develop, coordinate, and integrate statewide system.
* Generate information for use of BHHS, departments, and
regions in planning, decision-making and evaluation.
Recommended Policy
Legislation should be enacted, as part of the systems approach, to consolidate agency pro-grams as described in the preceding material. As recommended in the implementation discus-sion (later in this section), the Interim Transition Board for Health and Human Services would develop the work plan and implement the consolidation, which would begin in September 1993. The following guidelines should be used:
* Six departments should be created incorporating the programs from the existing agency structure.
* Each department should have a nine-member advisory board appointed by the Governor. Appointments to the advisory boards must be persons with a demonstrated interest in the service area in which they will be serving. Responsibilities of the advisory boards would include:
-- proposing policy, rules and regulations to be adopted by the Board of Health and Human Services (BHHS);
-- proposing operating procedures related to program-specific implementation;
-- making recommendations to the commissioner for hiring/firing the department director; and
-- reviewing and commenting on the department's budget prior to submission to the BHHS.
* Each department should be managed by a director, employed by the commissioner, after consideration of recommendations made by the relevant departmental advisory board. The departmental director will be responsible for:
-- providing services as a program consultant or advisor to the regions in developing and implementing programs including day-to-day technical advice;
-- developing program-related policy, rules, regulations and standards for service delivery and contracting;
-- developing training curricula and competency-based standards;
-- coordinating with the BHHS;
-- developing and implementing systems for monitoring the program performance; and, providing assurance that services are appropriate and being delivered effi-ciently;
-- providing information and expertise on services standards and rate-setting to the BHHS;
-- proposing a budget for the department which will feed into the statewide budget process; and
-- handling disciplinary proceedings for entities regulated by the departments.
Existing interagency planning programs and functions would be placed with the BHHS pend-ing a review by the interim transition board.
Because of the judicial responsibilities which will be assumed by the advisory board for the Department of Workforce Development, provisions will be made for a three member full-time, paid subcommittee which will perform the appellate duties now carried out by the existing Texas Employment Commission.
Implications
Successful reorganization can have significant positive effects. At the agency level, duplication of services and internal functions will be reduced and administrative functions will be shared. Coordination within agencies and among programs will improve due to the reduction in the number of agencies and the alignment on a functional, client-oriented basis. As health and human service agencies become more efficient, the state's capacity for meaningful strategic planning should increase.
However, reorganization can also have adverse effects. Under the Texas Performance Review proposal, state employee positions may be eliminated. These positions are all administrative, central office positions. No service delivery positions are proposed for elimination.
Fiscal Implications
Tables 20 and 21 show budgeted funds and positions prior to and following reorganization of agencies and departments. The amounts are based on budgeted figures for fiscal year 1991.
In consolidating 14 agencies into six departments, the assumption is that there will not be a need for the same level of administrative support staffing after consolidation. The assumption is that many support functions of the smaller agencies can be absorbed into the larger agencies. Based on these assumptions, the review estimates that approximately 300 support positions can be eliminated. These positions include accounting, purchasing, data processing, legal, contracting and personnel. No positions in direct service delivery would be eliminated. Reducing staffing at the agency level by an estimated 300 positions will reduce expenditures by $10.5 million (including employee benefits costs).
Table 20
Budgeted Funds and Positions by Agency Prior to Reorganization
Fiscal Year 1991
Agency Budgeted Funds Budgeted Positions
Millions Percent Number Percent
____________________________________________________________________________________________
Texas Department on Aging $ 57.0 0.8 % 56 0.1 %
Texas Commission on Alcohol and Drug Abuse 79.9 1.2 193 0.3
Texas Commission for the Blind 30.5 0.4 551 0.9
Texas Cancer Council 4.6 0.1 7 0.0
Texas Commission for the Deaf 1.0 0.0 11 0.0
Interagency Council on Early Childhood 23.1 0.4 22 0.0
Intervention
Texas Employment Commission 212.1 3.1 4,539 7.3
Texas Department of Health and Chest Hospitals 472.5 7.0 5,428 8.8
Texas Department of Human Services 4,594.3 67.6 19,014 30.7
Health and Human Services Coordinating 2.6 0.0 16 0.0
Council
Juvenile Probation Commission 21.4 0.3 22 0.0
Texas Department of Mental Health 1,039.0 15.3 27,864 45.0
and Mental Retardation
Texas Rehabilitation Commission 166.6 2.5 2,185 3.5
Texas Youth Commission 88.2 1.3 1,963 3.2
Subtotal $6,792.8 100.0 % 61,871 99.8*%
Additional programs assumed by new $251.2 N/A 118 N/A
HHS departments
Programs transferred to non-HHS agencies ($21.8) N/A (496) N/A
Total $7,022.2 N/A 61,493 N/A
*Does not total 100 percent due to effects of rounding.
Source: Texas Performance Review.
Table 21
Budgeted Funds and Positions Following Reorganization
Fiscal Year 1991
Department Budgeted Funds* Budgeted Positions
Millions Percent Number Percent
____________________________________________________________________________________________
Family Services $1,066 15.2% 12,684 20.7%
Health Services - Preventive Health 528 7.5 3,363 5.5
Health Services - Acute Care 2,349 33.5 1,171 1.9
Workforce Development 459 6.5 4,655 7.6
Rehabilitative Services 171 2.4 2,646 4.3
Community & Residential Services-Community 714 10.2 4,557 7.5
Community & Residential Services-Residential 1,555 22.2 25,872** 42.3
Protective & Regulatory Services 172*** 2.5 6,245*** 10.2
Total $7,014 100.0% 61,193 100.0%
* This table illustrates how funds and positions would be arrayed for fiscal year 1991 under the proposed reorganization. Numbers are based upon fiscal year 1991 program budget levels and employee data contained in agency legislative appropriations requests and Texas Performance Review projections of program positions to be eliminated. Refinements regarding the appropriate allocations of staff and funding for programs that do not distinctly fall into the new department structures will need to be worked out by the Interim Transition Board.
** Includes positions budgeted for state schools, hospitals and centers.
*** Includes an undetermined number of noninvestigative Child Protective Services Program staff who would be allocated to the Department of Family Services.
Source: Texas Performance Review.
A Comprehensive Approach to the Regional Administration
of Health and Human Services Should Be Established
Background
Planning and decision making for health and human services agencies usually occurs in Austin, but the actual delivery of services takes place throughout the state. A variety of mechanisms are used to administer these services. As shown in Table 22, six of the 14 health and human service agencies administer services in offices throughout the state and staffed by more than 23,000 employees. In addition, over 30,000 state employees deliver services through state facilities such as schools and hospitals operated by the Texas Department of Mental Health and Mental Retardation and the two chest hospitals operated by the Texas Department of Health.
Table 22
Health and Human Services
Filled Full-Time Equivalents (FTEs) by Location
December 1990
Agency Regional Facility Headquarters Total
FTEs FTEs FTEs FTEs
___________________________________________________________________________________
Texas Department of Human Services 15,565 --- 1,826 17,391
Texas Department of Health 2,208 798 2,072 5,078
Texas Employment Commission 3,285 --- 1,102 4,387
Texas Rehabilitation Commission 1,747 --- 365 2,112
Texas Department of Mental Health
and Mental Retardation --- 28,492 775 29,267
Texas Youth Commission 306 1,445 145 1,896
Texas Commission for the Blind 321 113 100 534
Other Health and Human Services
Agencies 0 __ 290 290
Total - All Agencies 23,432 30,848 6,675 60,955
Source: Information provided by each agency.
There are many problems in the Texas health and human services delivery system. For example, participants in a round-table discussion group conducted by Performance Review staff told of their circumstances and how the system is not working for them. For example, a middle class mother told the group that the system was "bisecting" her multiple handicapped five-year old. The system is also not working for the caseworker who told of spending substantial sums of her own money to provide transportation for clients.[15]
The system might work if clients experienced one problem at a time. For clients with more than one problem, however, multiple agencies and programs create a situation where: (1) it is difficult for families to access and use the programs that exist to help them; and (2) the programs, even when they are accessed, may not be able to address all of the problems and needs of the family simultaneously.[16]
Health and human service delivery systems in other states are confronting similar problems. According to a report from Minnesota: "Studies of the human service delivery system conducted in the mid-1970s concluded that the system was overly fragmented, program-driven, lacking system-wide planning and policy development, confusing to clients and not accountable for results. Over 15 years later, these problems have not been resolved. In some respects, they have grown worse."[17]
In a similar vein, a participant in California's 8th Annual Senate Budget and Fiscal Review Committee Retreat commented that: "There's not a single community in the state where there is a collaborative, coordinated system of services to track youth who drop out, or become pregnant, or go to jail....We attack the arm and the leg and the liver and the feet of the kid, but nobody is dealing with the kid as a whole in an organized way."[18] A panel discussion at the retreat concluded: "The panelists consistently identified the double challenge of meeting the needs of a growing and diverse population while remaining sensitive to the individual. The fragmented system presently in place must be replaced with a creative and integrated health and human services system if the complex needs of Californians are to be met."[19]
State Health and Human Service Delivery Regions. The lack of uniform regional boundaries make co-ordinated service delivery difficult. Health and human services in Texas have traditionally been delivered through a variety of region-like areas.
In 1975, groupings of the 24 state planning regions were used to designate the 12 Health Service Areas of Texas. The Legislature later reinforced the use of those boundaries as coordinating measures when the enabling legislation for health planning required the Texas Department of Health (TDH), the Texas Department of Human Resources (now the Department of Human Services) and the Texas Department of Mental Health and Mental Retardation (TDMHMR) to realign their boundaries so as to coincide with those of the Health Services Areas.[20] Today, most health and human service regions are based on the state planning regions designated in 1975, but the number of regions varies from five for the Texas Youth Commission (TYC) to 11 for the Texas Commission for the Blind (TCB). Both the Texas Department of Human Services (TDHS) and the Texas Department of Health (TDH) have regions, but TDMHMR has no regions per se. Sixty-three local service areas are used by TDMHMR for planning purposes.
The 24 Texas Planning Regions established in 1973 are made up of counties.[21] Within each region, regional councils--voluntary associations of local governments--deal with the problems and planning needs that cross local governmental boundaries. About 98 percent of the 254 counties in the state are members of regional councils.[22]
Texas has 254 counties which range from 128 to 6,169 square miles.[23] County populations range from 117 to 3 million.[24] Counties are a legal subdivision of the state and each has a commissioners' court and a county judge. Many counties offer health and human services.
Without uniform regional boundaries, coordinated service delivery, cross-regional comparisons, data collection, planning, communication, and evaluation is very difficult. A 1975 Council of State Governments report discussing state reorganization efforts noted: "Most would agree that if a centralized human resources agency is intent upon coordinating the delivery of human services, uniform regions are essential."[25]
Collaborative Strategies. Strategies for confronting fragmentation have focused on collaboration and community involvement. There is a definite trend among services agencies across the nation towards collaboration--of working together and focusing on prevention and the whole person or family--rather than on reacting to crises and the single need. A Yale study of collaborative endeavors launched by a wide range of education, Head Start, child-care and social-services providers found that "...collaborations are emerging as one solution to today's human-services challenges. Interagency collaboration is flourishing as a strategy to improve programs, conserve resources, and address family needs that transcend bureaucratic and policy structures." [26]
For example, health and human services offered at schools traditionally have involved employment and prenatal type services. New collaborations, in an effort to reach the entire family through the child, are offering a rather full range of health and human services at the public school level. Florida's "Full Service Schools" is an example of collaboration initiated at the state level.
Florida's Governor Lawton Chiles has pushed the "Full Service Schools" program which co-locates health and human service programs in schools. Services which are routinely provided include Aid to Families with Dependent Children (AFDC), food stamps, protective services and family planning. Two advantages of the Full Service School program include: (1) parents visiting the school to discuss AFDC payments or food stamps can also interact with the teacher; and (2) protective services counselors are an integral part of the school setting. Florida's goal is to have at least one full service school featuring one-stop family service centers established in each district during the 1991-1992 school year.[27]
A San Diego, California collaboration among city, county, school district and community college officials has resulted in "New Beginnings," an attempt to create, within a school, a more unified health and human services system and streamline the service delivery process. The services offered range from family orientations and needs assessments to health care and case management and referral. During a planning study, it was noted that families were less distrustful and more open in a school setting.[28]
A successful San Antonio state-community collaboration has involved the Texas Department of Human Services and the business community. Since l985, the San Antonio TDHS office has cooperated extensively with representatives of the private sector in a highly productive public-private initiative that focuses on an exchange of expertise. Corporate advisory groups have studied the department's internal operations in a number of areas. The department gained expertise on specific issues and corporate leaders also benefitted. For example, they learned of ways that their employee assistance programs can tap into community resources and realized that clients who became self-sufficient would be potential customers of the private sector's goods and services.[29]
These collaborations are part of a trend that also encourages community and non-profit based services -- programs designed to meet the specific needs of individuals and families as defined by their surroundings. The particular emphasis of these programs varies with the demographics and ethnicity of communities and the nature of their social problems. Most community-based social service programs, however, share the goal of providing a locally based, accessible, and non-bureaucratic alternative to assist individuals and families in their efforts to become more functional and self-sufficient.[30]
The advantages of community-based programs include: (1) programs tailored to client needs; (2) client centered service delivery; (3) fiscal efficiency (e.g., public funds that are available to community-based organizations are used to leverage additional funds from the private sector); and (4) responsiveness and cultural sensitivity.
Need for Change. Recognition of the need for change is not limited to the delivery of health and human services. Educators are addressing similar issues. Recently, Lionel Meno, Texas' incoming Commissioner of Education, discussed changes he envisioned making in the structure of Texas public education system: "What we need to do is move out of the program focus so we become more sensitive to the needs of local school districts and how they actually operate. Another thing we need to do is to put much more emphasis on looking at the product -- the results -- rather than looking at the process."[31]
To achieve agreed-upon health and human service system goals, a new service delivery system is needed in Texas. The January 1991, Texas Policy Academy report presented a vision of a new service delivery system: ". . .Texas needs a human investment system that is cost-effective, responsive, user-friendly, and emphasizes self responsibility. It must provide a continuum of integrated family-focused services that extend from prevention through recovery for all age groups. Additionally the system must measure outcomes so that resources can be targeted to the most effective service providers. The key question we need to ask is: How do we change the delivery system design?"[32]
The first step in changing the system is to define system-wide goals and the tactics the regions can use to implement them. Table 23 presents this information.
Table 23
Region-Level Tactics for Implementing System-Wide Goals
Relevant System-Wide Goals Regional Implementation Tactics
Develop a comprehensive, statewide approach One-stop eligibility
to the planning of health and human services. Co-location
Create a continuum of care for families and Case management
individuals. Non-traditional sites
Integrate service to provide for the efficient Community decision-making
and timely delivery of services. Client choices
Maximize existing resources through better
funds management and the sharing of admini-
strative functions.
Effectively use management information sys-
tems to improve service delivery.
Provide for system-wide accountability through
improved monitoring mechanisms.
Promote teamwork among agencies and provide
incentives for creativity.
Foster innovation at the local level.
Source: Texas Performance Review.
Regional Service Delivery Options. Service delivery options include direct delivery by state employees or the private sector, including for-profit or nonprofit businesses and volunteers. Shifting service delivery decision-making authority to the regions provides the flexibility to use resources efficiently, and to encourage innovation and community participation. As state governments push service delivery decision-making down to the regional and community levels, a variety of methods for purchasing health and human services can be considered. Innovation is encouraged in the search for ways to deliver services better and more efficiently. For example, Arizona relies primarily on non-profit community based organizations for service delivery because it feels that these organizations:
* promote competition;
* use smaller units which are capable of more flexibility or humanity;
* take advantage of the diversity of community organization to serve populations that are beyond the reach of state bureaucracy;
* are more flexible in shifting resources to respond to changing needs and circumstances; and
* make it easier to terminate contracts than to lay off civil servants.[33]
Seeking innovative service delivery approaches to contain costs and improve the quality of state services is simply good public policy.[34] Texas health and human services agencies presently purchase more services than are directly delivered by state employees. In fact, during fiscal year 1990, more than 85 percent of the services delivered to program clients were purchased. Purchasing, rather than directly delivering, services is not necessarily an indication that the current service delivery system is providing services more efficiently or responding to community needs. It does indicate, however, that there is a tradition of purchasing services, and that certain mechanisms related to contracting for those services are in place.
Alternative service delivery choices which make greater use of the private sector include those contained in Table 24.
Table 24
Private Sector Service Delivery Options
Service Delivery Options Description
_____________________________________________________________________________________
Contracting out/purchase Contract with private firms (profit or nonprofit) to provide goods or
of services delivery services, including administrative services.
Vouchers Provided to citizens needing the service. The citizen gives the voucher to the organization from which he/she has chosen to buy the goods or services. The organization obtains reimbursement from the region.
Grants/subsidies A financial or in-kind contribution to a private organization or individual to encourage them to provide a service so that the government does not have to provide it.
Volunteers Free help by volunteers who work directly for the region.
Self-help Groups or individuals such as neighborhood or community associations are encouraged to undertake for their own benefit activities that the region would otherwise undertake.
User fees and charges to Charge a fee to users of a service based on how much they use the adjust demand activity.
Encouraging private organi- The region gives up a responsibility for an activity but works with a
zations to take over an activity private agency (profit or nonprofit) willing to take over a responsi-
(divestiture) bility. This procedure may involve a one-time grant or subsidy.
Obtaining temporary help from Private firms lend personnel, facilities, or equipment or even provide
private firms funds to the region.
Source: Joan W. Allen et al., The Private Sector in State Service Delivery (Washington, D.C.: The Urban Institute Press, 1989), p. 2.
When making service delivery decisions, all options should be considered. Only when the range of available options has been considered in terms of cost and desired results, can the appropriate choice be assured. Factors to consider include: (1) ability to monitor service delivery, measure results, and take corrective action if necessary; (2) flexibility including ability to respond to changing needs and circumstances; (3) service quality; and (4) cost.
Comprehensive non-department based regions are consistent with the goals of an integrated health and human services system and greater community involvement. Comprehensive regions would make coordinated service delivery possible and facilitate implementation of client-friendly tools such as integrated eligibility and case management. The advantages of comprehensive regions can be enhanced by careful selection of the number of regions and their boundaries, and measures to improve coordination within the new regions.
Advantages of Comprehensive Regions. The reasons for creating a regional structure are usually associated with the following advantages:
* permits greater responsiveness to area needs through greater organizational flexibility;
* facilitates relationships with area residents;
* permits a quicker and better response to area problems;
* conducive to improved coordination;
* reduces physical distances which tends to improve communications;
* permits improved monitoring of problems, including cross regional comparisons; and
* decreases both travel and number of meetings.[35]
Factors to Consider in Deciding the Number of Regions and Boundaries. The size and number of regions would have a major impact on the decisions of a health and human services board relating to coordination and administrative control.[36] Determining the number of regions is not simple. Standard criteria such as economic, administrative, historical and geographic diversity should be considered as well as:
* related social service delivery boundaries such as state planning regions;
* boundaries of related state agencies such as Texas Education Agency;
* existing regional infrastructure;
* nature and needs of client populations; and
* location of other governmental entities.
In making the transition from the current regional structure to a comprehensive one, the number and location of employees and the number of clients using multiple services will be a factor. Using the existing TDHS regional infrastructure could expedite the transition process, given that 50 percent of all health and human services employees work for TDHS in 10 regions.
Achieving Coordination Within Comprehensive Regions. The act of creating comprehensive regions alone does not ensure an integrated service delivery system. Tools to help the process include co-location, case management, a single information and referral system within the region (which in fact might be statewide), effective use of regional planning boards and other citizens advisory groups, coordinated planning at the regional level, extensive staff training and development programs, and appointment of specific regional representatives to committees or task forces created to study particular regional coordination problems.37 All of these contribute to a cultural change -- a new way of looking at things, a new way of doing things. People who have participated in or evaluated changes in other states have said that this cultural change is a major factor in successful implementation of change.
Critical to the success of a comprehensive service delivery system are clearly defined roles and responsibilities and five key management control systems: (1) policy development and planning; (2) budgeting; (3) contracting; (4) quality control; and (5) information management. Although the rate of change among state health and human service agencies prohibits identification of a model delivery system, experiences of other states provide insights into what has worked and what has not. There are several lessons to learn from the Florida reorganization experience. First, department and regional roles and responsibilities should be clearly defined. Second, if integration of services and greater community involvement are goals, the regional administrator should have the authority to achieve those goals. Third, a cultural change is necessary to achieve any lasting success. [38]
The five key management control systems listed above, and clearly defined roles and responsibilities, are dependent upon an appropriate organizational structure to function properly. A decentralized health and human services organizational structure encourages regional decision making, which is appropriate for a high degree of innovation and responsiveness to the environment. As a 1990 study of the New York Department of Social Services noted: "A complex organization, more than others, needs simplicity in its organizational structure. Lines of responsibility, span of control, goals and objectives become more blurred if the organizational structure is not a point of clarity." [39]
A similar point was made during conversations with key health and human services agency officials in Texas and around the country, who generally agreed that a standardized regional structure is important for the dual purposes of communication and assessment. Within comprehensive regions, basic management control systems including planning, budgeting, quality control, information management and contracting should be uniformly developed and administered.
Policy Development and Planning. Policy development and planning at the regional level includes: (1) broadening the base of community involvement in the process to include local community groups, civic organizations, and private businesses; (2) communicating regional needs and concerns to the state level for state-wide planning; and (3) developing service delivery plans and strategies at the regional level. Types of regional planning include:
Statewide comprehensive planning: regions develop their own strategic, budget cycle, and operational plans for the state-wide planning process. The regional plan focuses on locally-identified needs and trends.
Regional service delivery planning: regional plans are developed using funds allocated to the regions as part of the statewide planning process. This plan designates how funds will be allocated within the region.
Regional planning, as well as system-wide planning, involves considering client needs and community priorities in terms of available resources. Table 25 lists region-level policy development and planning roles and responsibilities.
Table 25
Policy Development and Planning Roles and Responsibilities
Regional Planning Obtain input from community groups within region.
Boards Assess community needs and assign priorities.
Participate in regional policy development and planning process.
Make recommendations for resource allocations within region.
Regions Develop regional plan to feed into statewide planning process.
Based on regional plan, develop methodology for allocating resources within region.
Adjust plan as necessary, within parameters established by HHS Board.
Gather data needed for policy development, planning, allocating funds, and measuring results.
Departments Recommend department plans to be incorporated into the state-wide plan.
Provide input into regional planning process.
Develop service delivery standards for specific programs.
BHHS Develop statewide plan -- strategic, budget cycle, and operational.
Develop methodology for resource allocation to regions.
Recommend/approve changes to plan.
Two processes which contribute to statewide and regional policy development and planning are regional planning boards and data and information gathering:
Regional Planning boards offer an opportunity for community input into policy development and planning for service delivery. Planning boards should include representatives from various segments of the community including, public schools, community colleges, private business and other community and civic groups appropriate for the region. Community planning groups, or some other organization, can be used to provide for input from disparate areas of larger regions. Because of the diversity in Texas, the number and interests of participants required to provide adequate coverage will vary from region to region.
Data and information gathering supports policy development and the planning process. Data on client popula-tions and their needs, what service delivery techniques are working and what should be changed should be included. Data are also needed for contracting, rate setting, and resource allocations on three levels: state to regions, within the region, and for contracts.
Budgeting. As with planning, regional budgeting occurs at two levels: state-wide and region. Regional budgets are derived from planning goals and the information obtained during the planning process. Regional planning boards are also involved in the budgeting process. Table 26 lists budgeting roles and responsibilities.
Table 26
Budgeting Roles and Responsibilities
Regional Planning Based on information developed during planning process, participate in developing Boards regional budget request.
Regions Request department and planning board input into budget process.
Develop regional budget to feed into systemwide budget process.
During budget cycle, move funds within budget execution authority limits.
Departments Propose a department budget which feeds into systemwide budget process.
Provide input into regional budgeting process.
Make recommendations for programmatic component of systemwide budget.
BHHS Develop systemwide budget.
Determine regional budget execution authority.
Coordinate development and use of outcome-based measures.
An integral part of the budgeting process is developing outcome-based performance measures for evaluation purposes -- both during the cycle and at the end. During the budgeting process, the budget execution authority to be granted to the regions is decided. This authority provides for regional flexibility.
Quality control. Quality control systems attempt to achieve a balance between two potentially conflicting objectives: fiscal and quality control and improvement of services and their availability.[40] Accountability is as important to more effective governance of state agencies as is policy development and coordinated planning. "Planning" for quality control is part of the planning process.
The importance of quality control increases in a system as regional authority is increased. The challenge is to balance the advantages of regional authority--innovation and increased local involvement--with a quality control system that enables the Board of Health and Human Services to measure regional success in an efficient, effective manner.
An outcome-driven control system, measuring results rather than the process, is one approach. As educator Lionel Meno has noted: "When your whole accountability system is based on process, then people have to prove to you that they're putting the process in place. That takes reams and reams of paper. If you're able to shift to a results based system, then you're looking at the results of various assessments. You don't have the need to inspect everything. It's all part of a rather substantial systemic change that needs to take place."[41] Quality control roles and responsi-bilities that affect the regions are listed in Table 27.
Quality control procedures, even those that are outcome driven, can become excessive with multiple departments generating service delivery standards. A March 1990 study conducted by Arthur Andersen and Company for the State of New York discussed extensive and overlapping measures of audit and quality control among the various levels of the Department of Social Services and other governmental entities, and commented that although each has a purpose and can be helpful, "collectively the effort is uncoordinated, and excessive in relation to the Department's mission, purpose, and limited resources."[42]
Table 27
Quality Control Roles and Responsibilities
Regional Planning Board * Serve as an "early warning" for potential problems by providing input into regional quality control system.
Regions * First level of quality control focusing on results and accountability.
* Develop regional quality control plan.
* Quality control office responsible for auditing:
-- the service delivery function--both direct and that provided through contracting--according to region, department and policy standards; -- contracts--compliance with state law and federal regulations
* Report results to Regional Administrator and BHHS to be used in the evaluation process.
Departments * Develop program standards for both service delivery and contracting.
* Input into regional quality control plan.
* Participate in second level of quality control as coordinated through the BHHS.
BHHS * Approve regional quality control plan.
* Coordinate second level of quality control focusing on evaluating regional audit quality and additional procedures as necessary.
* Take action as necessary on regional quality control reports.
A four-stage process can be used to provide efficient, effective quality control:
(1) The Board of Health and Human Services and departments develop fiscal, quality control, and program service delivery standards which are circulated through the Office of the Assistant Deputy Commissioner for Regional Operations for review prior to regional implementation. These standards include consideration of both federal and state laws and regulations and professional standards.
(2) First level quality control is the regional quality control systems that perform the day-to-day audit function including services delivered directly by state employees, purchased, and volunteer services. The contract and on-site monitoring type activities occur at this level. The annual regional audit plan and audit results are submitted to the BHHS.
(3) Second level quality control is provided by the BHHS and departments as they routinely review the regional auditing function and perform audits as necessary. These audits are coordinated through the BHHS with frequency depending on individual circumstances.
(4) Results of both quality control procedures are fed into the health and human services evaluation system and corrective action is taken as necessary.
Contracting system. The term "contracting" is used to mean the process which results in a written agreement, enforceable by law, for provision of a service. The service provider may be a profit or non-profit enterprise or a volunteer. The elements of a contracting system include:
* a contracting data base including vendors, allocation information and monitoring information;
* standard contracting forms, including provision for output-based performance measures, monitoring and termination of contract if necessary; and
* program and administrative standards for negotiation, contracting and monitoring.
As new methods to deliver services are tried, both the type and frequency of monitoring and oversight changes. States which have allowed greater community decision making have noted the need for quality control systems focused on outcome based performance measures -- written into the contract and evaluated during and after the service delivery period. Similar concerns have been raised concerning TDMHMR's monitoring of community centers which provide a broad range of services.[43] Table 28 outlines contracting roles and responsibilities.
Table 28
Contracting Roles and Responsibilities
Regions * Develop service delivery goals and objectives.
* Perform cost/benefit analysis to evaluate service delivery options.
* Determine allocation methods required (e.g., contracting) and obtain
necessary information.
* Input related information into management information system.
* Quality control procedures to monitor/evaluate performance both
during and after contract period.
Departments * Set program performance and monitoring standards.
BHHS * Set administrative contracting, performance, and monitoring standards.
* Set rates as appropriate.
Information Management. The regional management information system (MIS) is the region's decision support system. This system provides the information necessary to plan, coordinate, contract, and control by: (1) serving as a scorecard to report on performance and results and measuring at the end of a period how well the agency has done; (2) drawing attention to problems by comparing what was supposed to happen with what actually happens; and (3) providing a basis for research and planning using both externally and internally-provided information. Table 29 presents regional MIS roles and responsibilities.
Table 29
Information Management Roles and Responsibilities
Regions * Input quality control, contracting, client, service delivery as well as personnel, payroll, inventory and procurement information.
Departments * Input program related information as well as personnel, payroll,
inventory and procurement information.
BHHS * Input administrative information as well as personnel, payroll,
inventory and procurement information.
* Develop, coordinate and integrate statewide systems.
* Generate information for use of HHS board, departments, and regions in
planning, decision making and evaluation.
Clearly Defined Service Delivery Roles and Responsibilities. The dual programmatic and administra-tive lines of authority in regional delivery systems make clearly understood reporting and communication channels important. Table 30 outlines service delivery roles and responsibilities.
Table 30
Service Delivery Roles and Responsibilities
Community Departments
Make needs known Set programmatic policies and standards
Supply providers Serve as a technical resource
Comment as part of evaluation/quality Provide quality control standards
Participate in vendor training Set program related training standards
Table 30 (continued)
Service Delivery Roles and Responsibilities
Regions Assistant Deputy for Regional Operations
Within HHS board and program standards: Monitor/evaluate regional performance.
allocate funds Evaluate regional administrator based on
deliver services goals and objectives
make adjustments necessary Participate in conflict resolution between
decide method of service delivery departments and regions
provide quality control Monitor standards
provide training Central point for information flow
to and from regions
Regional Administrator
Hire regional employees Assistant Deputy for Facilities Management
Achieve regional goals and objectives Monitor/evaluate facilities management
Develop relationships within community -- based on established goals and objectives
identify community-wide resources Central point for information flow to and from facilities
HHS Board
Set regional and facilities goals and objectives
Set parameters of regional budget execution authority
Set administrative policy and standards
Conflict resolution
Set administration-related training standards
Source: Texas Performance Review.
Recommended Policy
Comprehensive health and human services regions should be established by September 1, 1993.
When determining the number of regions and boundaries, consideration should be given to criteria such as economic, administrative, historical and geographical factors as well as:
* related social service delivery boundaries, such as counties and Texas Planning Regions;
* existing infrastructure;
* location of both worker and client populations; and
* boundaries of related agencies such as the Texas Education Agency.
A regional planning board should be appointed by the Board of Health and Human Services for each region. They would be responsible for:
* assessing community needs and assigning priorities;
* making recommendations for resource allocation;
* coordinating with other community groups; and
* providing input into evaluation process.
Regional administrators should report to the Assistant Deputy Commissioner for Regional Operations. They would be responsible for the following:
* recommending planning board representation within the region. Representation should reflect com-munity interests and include as applicable: public schools, community colleges, higher education, business community, governmental units, as well as clients and advocates. The size of the planning board will vary with the number of people needed for adequate representation;
* all regional employees;
* achieving region-specific goals; and
* maintaining key management control systems according to system standards.
Managers of residential care facilities should report to the Assistant Deputy Commissioner for Facilities Management. They are responsible for:
* all facility employees;
* achieving facility-specific goals;
* maintaining management control systems as directed by the Assistant Deputy Commissioner for Facilities Management; and
* providing services to regions as approved by the Assistant Deputy Commissioner for Facilities Management.
Implications
The Board of Health and Human Services should set service delivery policy. Options range from a decentralized structure emphasizing community based services and decision making, to a centralized structure with most services delivered by state employees. Each region should be treated as a separate service delivery entity with the BHHS making policy decisions and setting goals and objectives based on the characteristics of individual regions.
The relationship of the regions to the six departments should be one of day-to-day contact on technical matters relating to programs. These routine experiences should put the departments in the position to know what is working, or not working, for the regional service delivery staff and to determine if the situation is pervasive or limited to a few regions. This information then feeds into the evaluation, policy development and planning processes.
Fiscal Implications
Minimal fiscal impact is anticipated. The regional administrator positions and support staff will be funded out of current funding for the separate regional operations currently operated by existing health and human services agencies. There would probably be some fiscal impact in part as a result of the shift to comprehensive regional services delivery. This impact should not be extremely large, but it cannot be estimated from available data.
Implementation of a Systems Approach to Health
and Human Services Will Require Time
Background
The preceding issue discussions have articulated the need for a systems approach to the administration and delivery of health and human services and have provided the design of a model through which achievement of agreed-upon system goals may be possible. The model provides for: (1) a "super" board with the needed authority to permit system-wide oversight and coordination; (2) reorganization of existing agencies into six departments; and (3) consolidation of agency-specific administrative regions into comprehensive health and human services regions. The tactics which can be used at the board, department and regional levels to achieve system-wide goals have been described throughout the analyses.
Because of the magnitude of change involved in this plan, careful consideration needs to be given to ensuring that implementation of the structural model occurs in as efficient a manner as possible. While it will take several years to fully operationalize the model, implementation must be done expeditiously so as to limit the impact of uncertainty on existing agency staff and clients. A conservative estimate as to the amount of time between implementation and the time the model could become fully operational and subject to review would be four years. However, implementation of the model could begin within two years.
Implementation Plan. To ensure that implementation occurs in an orderly, judicious fashion, and that the negative impact of change on staff and clients is minimized, a detailed plan spelling out the steps leading up to and including implementation of the model needs to be developed. This plan will have to lay the groundwork and make provisions for the numerous contingencies which will evolve as the model is implemented. At a minimum, major components of the plan must include:
* Job descriptions for a commissioner, a deputy commissioner for regional administration, department directors and regional administrators;
* Defined department and region-level roles and responsibilities and organizational structure;
* Criteria for the number and boundaries of administrative regions;
* Operational plans, including cost estimates, for:
(1) centralization of administrative support services (e.g., personnel, payroll, inventory, procurement); (2) management information system integration;
(3) co-location and coordination of existing services (e.g., transportation);
(4) facilities management (e.g., renegotiation of existing leases);
(5) system-wide quality control (e.g., audit); and (6) development of purchased service standards;
* Recommendations regarding the composition and membership of departmental and regional advisory and planning boards;
* Recommendations regarding the need for and placement of interagency planning bodies and program-specific advisory committees;
* A specific timetable for model implementation and operationalization.
Interim Transition Board. Because of the need for objectivity and to avoid potential conflicts-of-interest, responsibility for the development of the implementation plan should be given to an interim gubernatorially-appointed health and human services transition board. The board would not have the authority to change the basic design of the model, but could make recommendations concerning needed modifications.
Recommended Policy
An interim transition three-member board should be appointed by the Governor during fiscal year 1992 to develop an implementation plan for the structural model and oversee the plan's implementation beginning in fiscal year 1994. The board members would serve on a full-time, paid basis until August 31, 1993.
Implications
In conjunction with the development of the implementation plan, the board would have the responsibility of developing a model-based legislative appropriations request (LAR) for affected agencies as well as a statewide, strategic plan for health and human services. This would ensure that program planning and funding issues and needs are consistent with and incorporated into the implementation plan. In addition, the interim transition board would assume responsibility for maximizing federal funds, tracking potential changes in federal funding and would work in conjunction with the Governor's office and the Texas congressional delegation in removing federal policy impediments to service delivery. Each of these responsibilities, along with responsibility for implementation oversight, would be assumed by the permanent health and human services board once implementation of the model occurred. Table 31 lists the major functions of the Interim Transition Board for Health and Human Services.
Table 31
Interim Transition Board Major Functions
Fiscal Years 1992-1993
Development of:
* a model implementation plan;
* a single legislative appropriations request;
* a statewide, strategic plan;
Responsibility for:
* federal funds maximization and monitoring.
Assuming that the interim transition board was appointed at the beginning of fiscal year 1992, it would submit its implementation plan and LAR to the governor and the 73rd Legislature in January, 1993. The legislature would base its decisions related to the funding of health and human services for the 1994-95 biennium on the board's plan and LAR. If approved by the Governor and funded by the Legislature, the implementation plan could become effective on September 1, 1993.
During the 1992-93 biennium, preparations would be made for full implementation of the model. The members of the permanent Board of Health and Human Services (BHHS) would be appointed by the Governor on September 1, 1992. The BHHS would work in conjunction with the interim transition board during fiscal year 1993 in planning for the full implementation of the model on September 1, 1993.
During fiscal year 1993, the BHHS would select a Commissioner of Health and Human Services. Members of departmental advisory boards would be appointed by the Governor no later than January 1, 1993. These members would assist the Commissioner of Health and Human Services in hiring departmental directors. The BHHS also would be responsible for appointing members of regional planning boards. At the end of fiscal year 1993 the Interim Transition Board for Health and Human Services would expire along with all existing health and human services agencies.
Although full implementation of the model would occur on September 1, 1993, it probably will take two biennia for the model to become fully operational. Therefore, a review of the BHHS and the departments by the Sunset Advisory Commission could occur during fiscal year 1998, with the subsequent findings and recommendations of the review presented to the 76th Legislature in January 1999. Table 32 presents the implementation timetable.
Table 32
Projected Implementation Timetable
Fiscal Years 1992 to 1999
September 1991 * Interim transition board appointed
September 1992 * Board of Health and Human Services appointed
January 1993 * Implementation plan and model-based legislative appropriations request submitted to the Governor and the 73rd Legislature
August 1993 * Interim transition board expires
* Existing agency structures expire
September 1993 * Model implemented
August 1997 * Model operationalization completed
September 1997 * Sunset review of model begins
January 1999 * Sunset review findings and recommendations presented to 76th Legislature
Fiscal Implications
Establishment of an Interim Transition Board for Health and Human Services. A two-year interim transition board with the aforementioned responsibilities will require significant professional, technical, and clerical staff support. Some staff can be assigned to the board by existing agencies. However, there will be a need for new staff as well as the assistance of consultants in areas requiring highly specialized knowledge and extensive experience. A conservative estimate as to the first year general revenue-related operating cost of the interim transition board is approximately $5.0 million which would provide for three full-time board members ($225,000); a director ($90,000); 55 Group 18 professional staff ($1,751,640); 16 Group 12 support staff ($332,352); fringe benefits ($664,520); and $1,936,488 for first-year support costs and professional fees which would include initial acquisition costs for computer equipment and software estimated at ($500,000).
An estimate of the number of full-time equivalents (FTEs) needed for each major function associated with the interim transition board is detailed below:
FTEs
Board Member 3.0
Director 1.0
Function
Development of a model implementation plan 30.0
Development of a single appropriations request 10.0
Development of a statewide, strategic plan 10.0
Responsiblity for federal funds maximization and monitoring 5.0
Support staff 16.0
Total 75.0
Establishment of a Permanent Board of Health and Human Services. The responsibilities of the interim transition board will be shared with the permanent Board of Health and Human Services which will be appointed in September 1992. While board responsibilities will change as a result of the shift in focus from implementation plan development to implementation oversight, it is assumed that staffing levels and related costs will remain constant. Because of the reduction in the need for administrative staff at the department level which will result from the reorganization of 14 agencies into six departments; however, board-related costs -- including the assumption of new responsibilities -- should be completely offset through the cost savings outlined below.
Reorganization of 14 Existing Agencies into Six Departments. The reorganization that would subsequently occur from the implementation of the model would provide for the elimination of an estimated 300 administrative FTEs. No service delivery-related positions would be eliminated. The 300 positions are identified as those existing in agencies that would be merged into the proposed departments. One of the interim transition board's duties would be to determine which staff resources would no longer be needed in the new structure. The final determination of which and how many positions would be eliminated would be made during the transition period and built into the legislative appropriations request for the 1994-95 biennium. For estimation purposes, however, Texas Performance Review staff has projected that 300 positions (approximately 5.0 percent of current administrative positions) could be reduced.
Elimination of these positions will save an estimated $10.5 million in funds. Savings realized from elimination of these positions would be used to support board functions as well as service enhancement. Consequently, there should be no change in each department's method of finance relative to federal funds availability and the use of state funds for match purposes.
Creation of Comprehensive Administrative Regions. Implementation of the model would eliminate duplication of regional administration responsibilities currently assumed by individual agencies - thereby producing savings that would offset any increased costs associated with the creation of comprehensive regions.
Fiscal Probable Cost to the Change in
Year General Revenue Fund FTEs
______________________________________________
1992 $5,000,000 75
1993 4,500,000 75
1994 0 0
1995 0 0
1996 0 0
Endnotes