Wisconsin's Innovative Approach to Long-Term Care
IRIS (Include, Respect, I Self-Direct) is a self-directed Medicaid waiver program from the Wisconsin Department of Health Services (DHS) Division of Medicaid Services. The ~$500 million program enables eligible adults to choose the long-term care (LTC) services they receive in their homes and communities.
PROBLEM: SILOS, SUSPICION, AND SPEND
Medicaid dollars consume a large share of state and federal budgets. With future funding levels uncertain, Wisconsin DHS wanted to move to IRIS, a self-directed program model, to be more cost effective. However, the various agencies providing services to long-term care benefit recipients were using separate, unconnected case management systems. This made it very difficult to coordinate care.
In addition, some Wisconsin lawmakers were concerned that a self-directed program might be more vulnerable to abuse or fraud — or at least the suspicion of fraud. To be successful, the IRIS waiver program would require a system that could easily track data, provide reports, and maintain tight controls in order to ensure that the program was being used properly.
SOLUTION: ONE CENTRALIZED CASE MANAGEMENT SYSTEM
Wisconsin DHS chose the Tyler Application Platform to provide the technical backbone of the IRIS program. The web-based platform offers modular, interoperable architecture that is a good choice for modernizing outdated Medicaid enterprise systems.
Authorized users access the platform to coordinate services and support LTC outcomes for IRIS participants, authorize and disburse payments to service providers, and manage and report on the program. These users represent all the various agencies providing services, and include social workers, nurses, and fiscal employer agents, as well as government analysts. Based on their role and system permissions, users can access, report on, and share HIPAA-compliant information as needed. As program needs or regulations change, technical staff can configure the system as needed.
In addition, the software provides advanced reporting and detailed audit capabilities to help protect the program’s integrity. Jordan Humpal, section manager of enterprise architecture and integration support for DHS, explains, “We can make sure that when participants submit claims and receive services, they’re doing so legally and not abusing their funds and budgets … We’re able to track all their activity, including the events they were performing and what records within the system they’ve accessed. There aren’t many cases where someone has tried to maliciously access the system, but if someone does, we can react swiftly because we have the records right there.”
RESULTS: IMPROVED OUTCOMES FOR RECIPIENTS AND FOR WISCONSIN
IRIS is one of the largest Medicaid Home and Community-Based Services 1915(c) waiver programs in the country, yet WI DHS operates the program with limited staff, reducing state administrative costs.
- Over 25,000 active participants today, having served more than 44,000 participants to date
- Allows 1,000 users from 14 different agencies to coordinate services and support LTC outcomes
- Saves tax dollars for Wisconsin, and contributes to better outcomes for individuals
- Provides program data to DHS, DOJ, and OIG analysts to support program decision makers. “Now, if someone says, ‘Can you get me this information I need?’ we can say, ‘Absolutely, just give us 30 minutes,’” Humpal explains. “We’ve been able to really streamline data exchanges and reports that other bureaus and divisions need.”
Solutions built on the Tyler Application Platform are used by benefits and entitlement programs throughout the public sector to manage millions of cases annually, including eligibility, care management, and claims processing.