Amid changing needs, Department of Health and Human Services charts ‘blueprint’ for new look in the future

Last modified: 2/9/2015 4:43:50 PM
What do Apple and the New Hampshire Department of Health and Human Services have in common?

Sure, maybe not a whole lot – right now, at least. One’s a tech giant with a reputation for producing sleek, wildly popular devices; the other is a branch of state bureaucracy responsible for Medicaid, mental health programs and monitoring disease outbreaks.

But Nick Toumpas, the head of the health and human services department, thinks his agency stands to learn from Apple’s transformations under Steve Jobs. Specifically, from the late innovator’s emphasis on the principle of “concurrent engineering.”

As explained in a 2005 Time magazine profile on Apple, the approach emphasized more collaboration across departments instead of the segmented organizational structure a lot of other companies traditionally relied on.

“The historical way of developing products just doesn’t work when you’re as ambitious as we are,” Apple design head Jonathan Ive told Time. “When the challenges are that complex, you have to develop a product in a more collaborative, integrated way.”

For Jobs and his colleagues, those products were computers and phones. For Toumpas, the “products” are services for the people of New Hampshire, sometimes matters of medical and overall well-being – and, therefore, markedly more complicated.

Toumpas’s agency, it’s worth mentioning, happens to be the largest in all of New Hampshire state government – in size and cost – and has to tackle some of the state’s most complicated problems. It uses about half of the state budget, and its recent caseload hovered around 174,000 people, according to the agency’s latest estimates.

As the responsibilities of the department (and the health care industry at large) are shifting dramatically, the structure has, more or less, remained the same in recent years. There are more than a dozen offices and divisions – the Office of Medicaid Business and Policy, the Division of Community Based Care Services, the Division of Public Health Services and so on – each with distinct but sometimes overlapping responsibilities, and many with their own long list of subdivisions. That also means that someone looking for help might be sent to several different “entry points” before they end up finding what they need, Toumpas said.

To weather the changes – and to better promote a “whole-person approach” to health, one of Toumpas’s mantras as commissioner – the department needs to change how it operates. And that, according to Toumpas, is where the lessons from Apple come in.

“It’s really getting these people together, so it’s not like having these people operate in a set of stovepipes,” Toumpas explained during a recent interview in his office, pointing to a draft of the department’s new operational model that occupies a good portion of one wall. “When we say, ‘This is what we want to do for adults, children, families, seniors and so forth,’ now you’ve got everyone sitting there saying 
. . . ‘How am I going to be able to really deliver on that? And how am I going to develop the quality? What is that going to mean from a customer service standpoint, and then what are all the enablers?’ ”

The department says its vision for these changes is to build “an organization that improves the health and independence of the people we serve by emphasizing a proactive and holistic approach.”

What does this mean for the people HHS serves?

Explanations of the department’s changes can easily become bogged down in corporate jargon. The organizational chart outlining the vision for the new operating model is peppered with phrases like “Inter-Agency & Gov. Synergy,” “Plan Coordination & Network Management” and “Resource Prioritization.”

So as part of its attempt to clarify things for current employees, the department created a video – produced internally, according to Toumpas – that tries to illustrate the changes in simpler terms.

“Each program area does their best to provide the services requested,” a voice narrates as a cartoon character is faced with multiple doors, meant to represent the myriad paths someone might take to approach the department. “Then the client must turn to an additional door to request services provided by another area of the department.”

But, the voice on the video asks, why?

“That’s the question we’ve been asking ourselves for quite some time,” the video continues. Why does someone who “comes to us for help must apply multiple times for assistance, just because a different part of the department oversees what they need?”

Part of the goal of reorganizing is to eliminate the department’s “design barriers” that make it hard for people to get the help they need in the most efficient way.

One way Toumpas plans to do that is by creating – or reviving, rather – an intake and assessment process for anyone who comes to the department for assistance. The agency used to do so decades ago, Toumpas said, but it fell out of practice.

Having all potential clients start at a single spot, Toumpas said, would make it easier for the department to be able to help people who might have multiple needs.

Take this example, Toumpas said: You have two people who are applying for food stamps with the department, but one of them has teeth and the other doesn’t. All things being equal, who’s going to have an easier time finding a job?

“The person with teeth, by a mile,” he said.

But if the department had a better way of knowing that someone applying for food stamps would also benefit from oral health care, Toumpas said, they might be able to connect them with those kinds of services – and, ultimately, help them out more in the long run.

“It doesn’t mean we’re expanding our portfolio of activities we’re going to do,” Toumpas said, and in fact the redesign could find the department reaching out more to partner with community-based organizations for certain services instead of trying to duplicate those services on its own.

A lot of the details of how, exactly, the department’s structure would look have yet to be ironed out. And Toumpas said he doesn’t plan on dictating specific instructions for sweeping changes in how, for example, some of the state-owned institutions operate.

“I’m not going to go into New Hampshire Hospital, Glencliff Home, and try to turn the place upside down,” he said.

And while Toumpas said the state’s transition to Medicaid care management – in which outside companies are beginning to coordinate care for the state’s Medicaid populations, transitioning away from the traditional fee-for-service model – isn’t driving the department’s move to change how it operates, the program does factor in.

“This effort began in recognition of the significant work ahead of us to implement multiple key initiatives such as the Medicaid Care Management Program and the New Hampshire Health Protection Program, with no increase in resources,” Toumpas explained in a department-wide email sent Jan. 5, updating employees on the status of the changes.

The state has been moving, incrementally, toward implementing this Medicaid care management program for several years.

Under that new approach, outside managed care organizations (“MCOs”) are taking on some responsibilities that would otherwise be performed by the department or community-based agencies – such as coordinating therapies or medical procedures. The department, in turn, is taking on some new responsibilities – monitoring what those companies are doing and how well they’re sticking to the terms of the state’s $2 billion contract, for example.

“There are things that we do today (where) we can streamline how we go about doing that,” Toumpas said. “There are things that we do today that the managed care organizations will be responsible for. There are things that we need to do, but we don’t do it to a sufficient enough degree – or we have people doing a particular function but now it’s going to be the responsibility of the MCO. We still have to have that oversight.”

As such, the people likely to see the most changes at first are those dealing with the “Medicaid enterprise” parts of the department: the Office of Medicaid Business and Policy, the Bureau of Behavioral Health, the Bureau of Developmental Services, Bureau of Elderly and Adult Services, and other related offices.

At this point, Toumpas hasn’t put a firm deadline on when he wants to complete the changes. In some areas, though, those changes have already started to manifest. When asked if the redesign will result in staff reductions, the commissioner said that’s not the goal. It’s also not driven by a desire to cut costs, he said. Still, though, Toumpas acknowledges that changing the department’s operating structure is part of facing the reality that it’s increasingly being asked to do more with less – in terms of both staff and funding.

Now that the department has plotted out its vision for its new focus areas and identified who will be in charge of those areas, there’s still a lot of work to be done.

“It provides us the blueprint and the game plan for what we need to do,” Toumpas said of the department’s adjustments thus far. “How quickly we do that is really driven by the need that we see.”

(Casey McDermott can be reached at 369-3306 or or on Twitter @caseymcdermott.)

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