Developmental Disabilities Administration Processes and Staffing

Executive summary

In 2022, the Legislature directed the Joint Legislative Audit and Review Committee (JLARC) to evaluate Developmental Disabilities Administration (DDA) processes for the following:

• Determining client eligibility.
• Assessing client service needs.
• Ensuring clients can access services.
• Managing the list of individuals waiting for services.

JLARC also must evaluate how DDA identifies its staffing levels.

DDA is charged with helping people who have developmental disabilities access services in their community

DDA is a part of the Department of Social and Health Services (DSHS). DDA's responsibilities include helping people who have developmental disabilities access services in their community.

• Services include help with daily tasks, skills training, employment services, community residential facilities, and caregiver respite.
• DDA contracts with third-party providers to provide services.
• State and federal Medicaid funding pay for the services.

Figure 1: JLARC staff identified five main steps to becoming a DDA client and receiving services

Source: JLARC staff analysis.

Some clients say the process of becoming a DDA client and receiving services can be long and confusing

JLARC staff contracted with the Institute on Community Integration (ICI) at the University of Minnesota to collect feedback from DDA clients and their representatives. Responses showed some variation in client experience. For example, many were happy with the application process and ability to access services. But others reported challenges like difficulty providing documentation or timeliness of the decision. Many thought the needs assessment was too long and repetitive.

DDA has not systematically analyzed how well its process helps people become clients and access services

DDA monitors some aspects of the process, such as the number of clients who have not been assessed. However, it does not analyze how well its process performs. For example, it does not know:

• How much time is needed to complete each step.
• How many clients cannot access services.
• How the process varies based on a client's location, demographics, or preferred language.

DDA also has not set relevant goals and does not consistently collect data that would be needed for performance evaluation.

The Centers for Medicare and Medicaid Services (CMS) recommends that states have systems to measure and improve their performance. Washington's Office of Financial Management advises agencies to understand current performance, determine ideal performance, set targets, and monitor progress.

DDA's case management approach prioritizes client assessments and planning over service connection and monitoring

CMS identifies four aspects of case management:

1. Needs assessment.
2. Planning.
3. Service connection.
4. Service monitoring.

According to case managers, DDA focuses on the needs assessment and planning. For example, case managers must assess each client and update their service plan annually. Clients cannot receive services without the assessment. DDA staff report that case managers' ability to help connect clients to services and monitor their progress is limited to time available after the assessments and planning are done.

Case managers and clients report that service connection may be limited to offering clients a list of providers.

DDA lacks adequate procedures, documentation, and quality reviews to ensure its published data is accurate and reliable

DDA staff have minimal documentation about how its staff should retrieve information from its client database. New staff have little guidance for creating routine reports, replicating data that was previously published, or fulfilling data requests. This has led to the agency struggling to provide and report accurate data.

Best practices state that agencies should adopt policies and practices to ensure the accuracy and reliability of information they make public. This includes documenting methods and reviewing information before it is distributed. DDA staff report that they are in the process of developing documentation.

DDA's approach to determining staffing levels is not based on a workforce planning approach

At the Legislature's direction, DDA published a plan to reduce the number of clients each case manager works with on the general caseload from 75 to 35. JLARC staff found that the target ratio of 1 to 35 was based on inaccurate information published in a 2019 report to the Legislature.  

Best practice for determining staffing levels is to use a workforce planning approach. It has six steps:

1. Determine how the case manager position aligns with the agency's strategic plans, goals, and resources.
2. Identify ideal process performance (e.g., how long each step should take).
3. Assess current structure and process performance.
4. Analyze the gap between ideal and current performance.
5. Create a workforce plan that specifies the tasks, strategies, and resources needed to achieve ideal performance.
6. Implement and monitor the plan to ensure it achieves the strategic direction.

Legislative Auditor's recommendations

1. DDA should develop and use performance metrics to evaluate how well its process works for clients and improve timeliness.
2. DDA should implement quality controls to ensure the reliability and accuracy of data used for reporting and performance management.
3. DDA should use a workforce planning approach to determine the number of case managers and other staff it needs.

You can find additional information in the Recommendations section.

Part 1.
DDA

State law defines a developmental disability as one that:

• Starts before a person is 18 years old.
• Is expected to continue indefinitely.
• Constitutes a substantial limitation to the individual.
• Is attributable to cerebral palsy, epilepsy, autism, intellectual disability, or another neurological or other condition closely related to an intellectual disability.

Developmental Disabilities Administration (DDA) exists to help people who have developmental disabilities

State law requires DDA to help people who have developmental disabilities. Clients may be eligible for services like help with daily tasks and skills training. DDA contracts with third-party providers to provide services.

The 2022 Legislature directed JLARC to evaluate the processes that DDA uses to determine eligibility, assess service needs, and ensure its clients can access services. The study also must assess how DDA manages its staffing levels and the list of individuals who are waiting for services.

Medicaid funds DDA services and operations

In the 2021-23 biennium, DDA spent $4 billion in Medicaid funds for home and community-based services and related DDA administration. Of this, about 41% was state funds and 59% was federal. In fiscal year 2024, DDA spent $2.4 billion for services and administration. This was split 49% state funds and 51% federal.

DDA is organized to offer services across the state

DDA is headquartered in Olympia. It has three regions and 30 field offices.

• Headquarters sets agency policies and procedures, develops statewide training, monitors Medicaid compliance, and coordinates between regions.
• Regions create local training, develop service provider networks, and operate the field offices. While they must follow agency policy, each region can tailor its approach to meet the local needs.
• Field offices are responsible for working with clients.

Figure 2: DDA has three regions to serve clients

Source: JLARC staff depiction of information provided by DDA.

Case managers are the primary point of contact for DDA's clients

As of July 2024, DDA employed 680 case managers.

• About 90% of the case managers are responsible for working directly with clients to assess their needs, develop service plans, and help connect them to services.
• About 4% process applications and determine if individuals are eligible for DDA services.
• The remaining 6% work with clients who are eligible but not currently receiving services.

Case managers work in field offices across the three regions. Some regions give certain case managers specific duties. For example, regions have assigned case managers to help clients navigate the initial needs assessment, financial, and federal eligibility processes.

About 70% of DDA's case managers were hired in the last four years. DDA staff estimate it takes multiple years for a new case manager to be fully trained.

Part 2.
Clients

As of July 2024, DDA had 58,068 enrolled clients. DDA categorizes clients into two broad groups:

1. Paid Services (71% of clients).
1. These clients receive services paid for by DDA.
2. No Paid Services (29% of clients).
1. These clients are not currently receiving services paid for by DDA.

Of the Paid Services clients, 99% live and receive services in their homes and communities. The others live and receive services at institutions like the state-run residential habilitation centers.

Figure 3: 71% of the DDA client population receives paid services

Source: JLARC staff analysis of DDA data.

Paid Services clients typically have a waiver and Community First Choice funding

Paid Services clients generally receive service funding through a Medicaid waiver, a Medicaid entitlement program called Community First Choice, or both.

The majority (94%) of DDA clients who are four or older receive paid services through a Home and Community Based Services waiver. This means that they waive their right to receive services in an institution so that they can receive services in their community.

• Washington has five Home and Community Based Services waivers. Each waiver is designed to meet different needs and limits the number of clients that participate (i.e., waiver spots). Some waivers have specific caps on the annual expenses per client. The annual expenses on all waivers must not exceed the average daily cost of an institution.
• Each waiver offers a different package of services. Some services, such as transportation and specialized equipment and supplies, are offered on all waivers. Other services, such as residential services, are only offered on two waivers.
• Clients are not entitled to a waiver. Clients can participate in one waiver at a time. They can change waivers as needed, subject to availability.

Clients also can receive services through the Community First Choice entitlement program. It gives clients access to personal care services, such as help with eating, dressing, bathing, and other tasks. Everyone who is eligible and wants to use these services receives them. Clients can be on a waiver and receive Community First Choice at the same time.

DDA is working to identify why clients are on the No Paid Services caseload

As directed by the Legislature, DDA began collecting information about its No Paid Services clients in 2021. DDA contacted over 6,000 clients through surveys, phone calls, or case management since 2021. It reports a variety of reasons that clients may not receive services. For example, some may not currently want services. Others may not know how to ask for services or may be waiting for an assessment. DDA began publishing data about the most common reasons in its December 2024 report to the Legislature.

DDA began offering case management to these clients in January 2024. Case managers are responsible for contacting clients at least once per year, updating client information, facilitating requests for services, and conducting assessments.

A higher proportion of No Paid Services clients are children

In July 2024, 63% of No Paid Services clients were children. In contrast, 47% of the Paid Services clients were children. Parents are encouraged to enroll their children into DDA before they need services.

Figure 4: Compared to Paid Services clients, a higher proportion of No Paid Services clients are children

Source: JLARC staff analysis of July 2024 DDA data.

No Paid Services and Paid Services clients differ demographically. Reasons are unknown.

JLARC staff found that between Paid Services and No Paid Services clients, there are differences in race, ethnicity, tribal affiliation, and language preferences. We found no significant differences in gender, disability, or location.

• No Paid Services clients are more likely to identify as Hispanic or Latino, and less likely to identify as white.
• More No Paid Services clients report they are affiliated with a Tribe: 15% compared to 2% of Paid Services clients.
• Among No Paid Services clients, 12% have a primary spoken language other than English and 8% need translated documents. For Paid Services clients, it is 9% and 5%, respectively.

DDA does not currently evaluate disparities between the client groups. JLARC staff were unable to evaluate why the demographic differences exist because DDA does not collect sufficient data (Part 5).

Figure 5: No Paid Services clients are more likely to identify as Hispanic or Latino, and less likely to identify as white

Source: JLARC staff analysis of July 2024 DDA data.

Clients who are waiting for a waiver are on a service request list

RCW 71A.10.020 defines a service request list as the list of clients eligible for a waiver and denied access due to funding limits. DDA tracks the number of clients who have been denied a waiver spot due to lack of waiver capacity. The number of clients waiting for a waiver declined from 1,411 in 2020 to 34 in 2023, a 98% decrease, due to funding from the Legislature.

Of the 34 clients on the service request list in 2023:

• 33 are Paid Services clients. They may be receiving paid services under a different waiver or through Community First Choice.
• 1 is a No Paid Services client.

Part 3.
Client experience

JLARC staff identified five main steps to becoming a DDA client and receiving services.

• Both clients and case managers must take specific actions to complete each step.
• Clients typically have family members or friends act as their representatives and help them through each step.

Figure 6: Clients and case managers have responsibilities

Source: JLARC staff analysis of DDA documents and staff interviews.

JLARC staff worked with experts to evaluate DDA's process

JLARC staff contracted with the Institute on Community Integration (ICI) at the University of Minnesota to survey and interview DDA clients and their representatives to learn about their experience with DDA's process. This was a voluntary sample: ICI invited 21,400 people to complete a survey, and 421 did so. ICI randomly selected 48 survey respondents for additional in-depth, semi-structured interviews.  

ICI also sent a voluntary survey to 793 DDA case managers and supervisors. Of these, 102 staff members responded. The approach and methods are detailed in Appendix A.

Some clients find the application step long and confusing

In the client survey, 53% reported a good overall experience applying for services through DDA. The remaining 47% reported a poor experience.

Clients and their representatives also reported challenges in the application step including:

• Total length of time to complete the step.
• Identifying and gathering records.
• Unclear communication.
• Little information about the application status.
• Length of time for the eligibility decision.

DDA does not track how often applicants have difficulty providing documentation. However, DDA case managers told JLARC staff that incomplete applications often delay the process. ICI heard similar comments from case managers that process applications. In October 2024, DDA updated its website to make eligibility information and required documentation clearer.

Clients and DDA staff note that assessment is long and repetitive

DDA's assessment determines whether the client is functionally eligible for a Medicaid waiver and identifies the services the client will need. Functional eligibility means the person has support needs that qualify them to receive services. Clients cannot receive services without an assessment. The assessment is completed annually (Part 4).

Clients and their representatives believe the assessment is too long, and that it asks unclear and repetitive questions. Of the 72 staff respondents who handle assessments, 57% reported that it is too long. They also noted that it is repetitive and can have an emotional toll on clients. They note that a lack of multilingual case managers and experienced interpreters poses additional challenges.

Case managers use the assessment results to develop a service plan. In interviews, 12 out of 48 clients and their representatives stated that DDA does not develop the clients' service plans in a collaborative way. They also expressed concern that the plans do not include sufficient information about the client's strengths.

While many clients have a good experience accessing services, others report outdated information and a provider shortage

After a client completes the assessment, the case manager gives them a list of contracted providers to choose from. Once the client selects and contacts a provider, services can begin.

About half of the clients and representatives who ICI surveyed said they had a good experience connecting to services. However, a third did not.

Client feedback and JLARC staff analysis reflected three themes:

1. DDA did not have an easily accessible list of available services. DDA addressed this concern in October 2024 by listing services for children and adults on its website.
2. The provider lists that DDA gives to clients have contained outdated contact information and providers that were no longer accepting clients.
3. Clients found there was a lack of available providers and long wait times for some services across the state.

DDA staff echoed the concerns. They noted that each region and DDA headquarters maintain separate lists. The information available to clients depends heavily on their location and case manager.

The extent of provider shortages in Washington is unclear. Regions reported varying levels of difficulty in provider shortages. Academic literature and federal research reports that there is a nationwide problem with the shortage of providers.

Some clients also reported difficulty knowing what services were available

16% of clients and representatives reported that their case managers did not provide sufficient service options. Some clients reported turning to other families or advocacy organizations to learn about potential services. While agency rules define and list service type, it was difficult to find a comprehensive list elsewhere, including on DDA's website. In October 2024, DDA began updating its website, which may make information about services easier to find in the future.

DDA has limited information available to help clients understand the steps

Some tasks in the eligibility process are the client's responsibility. JLARC staff found that DDA did not provide clear, easily accessible information about each step. In fall 2024, DDA created a webpage that outlines eligibility steps, but it does not indicate how long each step should take. As described in Part 5, DDA has not analyzed data necessary to inform clients of the length of steps in the process. Without a clear roadmap, clients may find the process confusing and may expect shorter timeframes.

With the website update, DDA's guidance on how to submit a DDA application and a list of required documentation is more accessible. This may help address some of the challenges that clients face. For example, the website more clearly:

• Identifies the steps to apply for DDA eligibility and request services. There are hyperlinks to more information and contacts.
• Links to a downloadable document with eligibility criteria by age group and lists the tests that are accepted as evidence of disability.

Figure 7: DDA's website update in 2024 improved information for clients

Source: Screenshots from DDA website as of November 7, 2024.

Every state has a different approach to assisting people

JLARC's consultant, ICI, researched practices that state agencies should consider when determining client eligibility, assessing client needs, and ensuring clients can access services. ICI reviewed how Washington's DDA process and practices compare to other states.

ICI found that there are few standard ways that states implement processes for eligibility, needs assessment, and service connection. This is consistent with the findings from the National Association of State Directors of Developmental Disabilities Services, which notes that every state has a different approach, making interstate comparisons challenging.

Based on client concerns in Washington, ICI identified practices used in other states that could be beneficial. It suggested that DDA develop an online application system, shorten assessments, focus on the client's strengths and goals in service planning, and create an accessible database of service providers.

Part 4.
Case management

The Centers for Medicare and Medicaid Services (CMS) identifies four core elements of case management in 42 CFR § 440.169:

1. Needs assessment: The assessment determines an individual's service needs.
2. Person-centered planning: Person-centered planning involves the collaborative development and implementation of a service plan based on a client's goals and information from the needs assessment. The plan outlines how clients will access the services and supports they need.
3. Service connection: Case managers help people obtain needed services, including connecting people with providers or other programs and services.
4. Service monitoring: Case managers ensure that the service plan is effectively implemented and addresses the needs of the person. If services in the plan are not meeting the client's needs, the case manager helps assess if changes should be made.

DDA emphasizes client assessments and planning over other aspects of case management

Based on interviews with DDA case managers, ICI learned that DDA's current system of case management primarily focuses on assessment and planning. It leaves little time for service connection and monitoring.

For example, DDA requires case managers to assess each client and update their service plan annually to comply with Medicaid rules. DDA emphasizes assessments because clients cannot receive services without an assessment. Case managers are responsible for helping clients connect to services. However, this may be limited to offering a list of providers for the client to contact. DDA staff report that case managers' availability for monitoring is limited to time available after assessments and planning are done.  ICI and DDA staff noted that the focus on assessments makes it difficult for case managers to gain in-depth and current knowledge about services and regional providers.

DDA's emphasis on assessments is reflected in its training as well. New case managers attend a two-week training that focuses on the assessment and plan development. They receive additional assessment training from their regional offices. DDA does not have a similar level of emphasis on training for service connection and monitoring.

DDA uses a support assessment and a service level assessment to inform the client's service plan

DDA's assessment determines waiver eligibility and the services a client needs. It includes a support assessment and a service level assessment.

• The support assessment establishes functional eligibility for a waiver and determines what services are needed. There are two tools: one for adults and one for children.
• The service level assessment calculates the number of personal care hours a person can receive. "Personal care hours" means paid help with eating, dressing, bathing, and other tasks. The same tool is used for adults and children, and modified to be age appropriate for children.

In general, a case manager completes both assessments in a single visit. Both assessments include a series of questions about what supports the client needs for daily living and what supports they currently have.

The results of the assessments inform a service plan. The plan includes the list of paid services the client may receive, a description of the client's informal supports (e.g., unpaid supports provided by a family member), and the client's goals.

Figure 8: DDA completes two assessments and uses three tools

Source: JLARC analysis of DDA materials.

Assessments are time consuming and must be repeated annually

DDA estimates that case managers typically spend 3 to 6 hours interviewing the client and their representative for the full assessment. DDA does not collect data on how long assessments last. Case managers spend additional time preparing for the assessment and creating the plan. If a client needs an interpreter, this can significantly increase the time it takes to complete the assessment.

JLARC's consultant, ICI, states that an assessment should last no longer than 2.5 hours. A longer assessment could lead to fatigue and less accurate responses. ICI recommends that longer assessments be divided into multiple meetings.

Case managers must reassess clients annually. DDA requires that:

• The Supports Intensity Scale must be completed in full every five years. A shorter version may be used in other years.
• The Children's Support Assessment must be completed in full each time.
• The Service Level Assessment must be completed in full each time.

DDA has considered options to shorten the length of the assessments. For example, a DDA study issued in November 2024 recommends that it use dedicated staff to administer the assessment. DDA's three regions have piloted having some case managers dedicated to specific steps, such as doing initial assessments or guiding clients through the financial and federal eligibility processes.  However, DDA has not evaluated these regional strategies for statewide implementation. Therefore, it is not clear whether this approach will be more efficient or produce more consistent evaluations.

Service Level Assessment may not reflect needs of DDA's population

The Service Level Assessment is designed to ensure that individuals who have similar needs will receive the same number of personal care hours, regardless of disability or age. CMS approved the assessment and DDA uses it for all clients who want paid services.

JLARC's consultant, ICI, reviewed the Service Level Assessment and found that:

• Much of the Service Level Assessment was developed for an elderly population who are served by the Aging and Long-Term Service Administration (ALTSA), receive similar waivers, and live in nursing facilities. ALTSA is a separate DSHS administration that serves seniors and people with disabilities. Like DDA, clients receive Medicaid-funded personal care.
• It is unknown if the assessment accurately captures the number of personal care hours necessary for the people who have developmental disabilities and are living in the community.
• The Service Level Assessment and the support assessments cover many of the same topics, although the specific questions are different. Some clients and their representatives told ICI that the two assessments seemed repetitive.

There is no clear best practice for assessments to determine personal care hours. States use a variety of methods. For example, Oregon uses a single assessment to determine both waiver eligibility and personal care hours. Its tool is specific to individuals with developmental disabilities.

DDA's November 2024 study of its assessment process focused on the support assessment. As DDA considers future changes to the assessment, it could consider whether there are opportunities to amend the Service Level Assessment to shorten the assessment and ensure it reflects the needs of the clients it serves.

Part 5.
Data & performance

DDA manages client case files in a database that records client demographics, assessment information, service authorizations, and client contacts. DDA uses the database to generate data for its primary public report, the annual Caseload and Cost Report. It also uses the database to respond to external data requests. DDA's system has limited ability to provide data in a format that could be compiled and used to evaluate performance.

DDA has minimal documentation about data retrieval and does not have effective quality control processes

DDA staff have minimal documentation about how to retrieve information from its client database. New staff have little guidance for creating routine reports, replicating data that was previously published, or fulfilling data requests. This has led to the agency struggling to provide and report accurate data. For example:

• JLARC staff identified errors in the formulas used to produce the Caseload and Cost Report. DDA double-counted 256 clients and put 2,095 (4%) clients in the wrong age category. DDA replicates information from the Caseload and Cost Report in other reports, including those submitted to the Legislature.
• DDA had difficulty providing consistent and accurate client data to JLARC staff. These challenges persisted over multiple data requests.

DDA does not have quality control processes like those used in other divisions of DSHS. For example, DSHS's Technology Innovation Administration (TIA) uses a documented process with built-in quality checks to ensure it produces accurate data. DDA staff report that it is not always feasible for DDA to use TIA's process and still fulfill data requests in a timely manner.

Documenting policies and procedures can ensure data quality

Best practices state that agencies should adopt policies and procedures to ensure the accuracy and reliability of information they use or make public. This includes documenting methods and reviewing information before it is distributed. DDA staff report that they are in the process of developing documentation. Documenting procedures and ensuring accurate data retrieval can help agencies reproduce data for recurring reports and generate commonly requested data more efficiently.

DDA does not evaluate how well its process performs

DDA has some monitoring and quality control measures in place. For example, managers monitor how many clients are overdue for assessments. DDA also reviews a sample of eligibility determinations and service plans to ensure laws and CMS regulations were correctly implemented. DDA recertifies case managers to conduct support assessments annually.

However, these activities do not evaluate how well DDA's eligibility, needs assessment, and service delivery process performs. For example, DDA does not systematically analyze:  

• Time to complete steps such as:
• Receipt of application to eligibility determination.
• Assessment length.
• Service request to completed service plan.
• Plan acceptance to starting a service.  
• Number of incomplete applications due to missing records.
• Number of clients who cannot access authorized services and reasons why (e.g., cannot find available providers).
• Whether client experiences vary based on region, race/ethnicity, age, or preferred language.

Understanding current performance would help DDA ensure it is meeting its own rules, set relevant goals, manage client expectations, and make targeted improvements to its operations. This would also allow DDA to assess how process changes affect timeliness or other metrics.

However, if DDA uses data to analyze performance, it will need accurate data to do so, further emphasizing the need for policies to ensure data quality.

Performance measurement is a best practice and is used in other parts of DSHS

CMS recommends that states have systems in place to measure and improve their performance. This may include "identifying and tracking performance in achieving critical participant outcomes, assessing how effectively the waiver supports participants to direct their services, or improving the capabilities of waiver providers to effectively support participants."

The Washington Office of Financial Management (OFM) performance measurement guide states that agencies should understand their current performance, determine ideal performance levels, and set targets to meet the ideal performance. OFM identifies five steps for agencies to take:

1. Understand their current performance.
2. Gather information about ideal performance.
3. Compare the results of steps 1 and 2.
4. Consider if it is a part of an agency's strategic priorities and what resources there are.
5. Set the improvement target.

Other parts of DSHS track performance of their processes. For example, ALTSA evaluates the timeliness of its initial assessments and financial eligibility determinations.

Part 6.
Staffing needs

DDA bases its staffing approach for case managers on the ratio of case managers to clients.

• The majority of clients are on a general caseload, which has a ratio of one case manager per 75 clients.
• Some caseloads, such as those for high-risk children or adults with intensive needs, have lower ratios. Details are in Appendix B.

DDA based a proposed reduction of its general caseload ratio on inaccurate information

As directed by the Legislature, DDA created a plan to reduce the case manager to client ratio of its general caseload from 1:75 to 1:35.  In 2024, it requested staff and funding to implement the first phase of its plan. The 2024 Legislature partially funded this request.

The goal of a 1:35 ratio was set based on inaccurate information published in a 2019 report to the Legislature. The report incorrectly suggested that the national average case manager to client ratio was 1:31. This figure actually reflected case management data from a single state.

In 2022, DSHS conducted a national survey about case management. It received responses from 16 states. JLARC staff's review of the results found that case manager job duties and caseload ratios varied significantly. For example, ten states reported using private or nonprofit agencies to conduct client assessments.

Comparative ratios are insufficient for setting caseload sizes

The National Association of State Directors of Developmental Disabilities Services advises against comparing caseload ratios between states because there are significant variations in program structures.

Optimal caseload size depends on the following:

• Scope of duties of the case manager.
• Intensity of needs of the individuals for whom the case manager provides support.
• Robustness of the services provided to the individual.
• Extent to which the case manager has support from other professionals and paraprofessionals.

Best practices for staffing could help DDA achieve optimal caseload ratios and improve performance

Instead of creating caseload ratios based on other state comparisons, DDA could use a workforce planning approach. Workforce planning is:

• A method for identifying the size and composition of a workforce needed to achieve an organization's goals and objectives.
• A way to achieve optimal caseload ratios within the constraints of strategic goals and resource allocation.

Best practices, such as those developed by the Government Accountability Office and the federal Office of Personnel Management, suggest agencies take the following steps:

1. Determine how the case manager position aligns with the agency's strategic plans, goals, and resources.
2. Identify ideal process performance (e.g., how long each step should take).
1. Incorporate performance measures, as discussed in Part 5.
3. Assess current structure and process performance.
1. Use a workload study or similar tool. DDA completed a workload study in 1999 that reflects many of the workforce planning best practices. Case managers' job duties have changed since then.
4. Analyze the gap between ideal and current performance.
5. Create a workforce plan that specifies the tasks, strategies, and resources needed to achieve ideal performance.
1. Consider client population growth, staff turnover, and options to change the case manager duties (e.g., dedicated staff for assessments).
6. Implement and monitor the workforce plan to ensure it achieves the strategic direction.

As discussed in Part 4, the Legislature directed DDA to explore ways to improve the assessment process. A DDA study issued in November 2024 recommended using dedicated assessors, which would shift some duties away from other case managers. Changes to case managers' duties, DDA's intent to perform other aspects of case management, and legislative direction to reduce caseload ratios underscore the need for a workforce planning approach.

Recommendations

The Legislative Auditor makes three recommendations.

Recommendation #1:
DDA should develop and use performance metrics to evaluate how well its process works for clients and improve timeliness.

DDA should adopt performance metrics that will allow it to make targeted improvements to the application/eligibility, needs assessment, and service access steps. As best practices state, DDA should first understand its current performance and then measure performance on an ongoing basis. Metrics should include measures on consistency and timeliness of the process steps, such as how long it takes a client to receive a determination from when they apply, how long assessments take, and how long it takes for clients to connect to a service. Metrics could consider processes by demographics, location, and preferred language, among other factors DDA deems necessary. DDA should use the metrics for ongoing evaluation and update them as needed. Once DDA understands its timeliness performance, it should publicly communicate timelines to applicants, clients, and interested groups so they understand how long the processes take.

DDA should adopt performance metrics by June 2026, with the full system operational by June 2027.

Legislation Required: No

Fiscal Impact: JLARC staff assume this can be completed within existing resources. If DDA believes additional resources are needed, it should include that information in its future budget requests.

Implementation Date: June 2027

Agency Response: To be included in proposed final report.

Recommendation #2:
DDA should implement quality controls to ensure the reliability and accuracy of data used for reporting and performance management.

DDA should create policies and procedures to ensure the agency is reporting accurate data. Resources within DSHS can help DDA with quality control review. Also, Washington's Office of Financial Management and Washington Technology Solutions (WATech) have issued guidance documents for state agencies related to data management.

Legislation Required: No

Fiscal Impact: None

Implementation Date: December 2025

Agency Response: To be included in proposed final report.

Recommendation #3:
DDA should use a workforce planning approach to determine the number of case managers and other staff it needs.

DDA should create a workforce plan using workforce planning best practices. Agencies use workforce planning to identify the human resources they need to meet goals and objectives. DDA should first determine the tasks required to fulfill the four elements of case management discussed in Part 4. It should then determine how case managers currently spend their time. To develop its workforce plan, DDA could use a method similar to its 1999 workload study, or a different approach. DDA can then analyze the gap between ideal and current performance. Based on that information, DDA should develop caseload ratios and a workforce plan specifying the tasks, performance, and resources needed to achieve ideal performance.  

Legislation Required: No

Fiscal Impact: Depending on the approach DDA takes, it could be completed within existing resources, or it may need additional resources. If DDA believes additional resources are needed, it should include that information in its future budget requests.

Implementation Date: December 2026

Agency Response: To be included in proposed final report.

Agency Response

To be included in proposed final report.

Current Recommendation Status

JLARC staff follow up on the status of Legislative Auditor recommendations to agencies and the Legislature for four years. The most recent responses from agencies and status of the recommendations in this report can be viewed on our Legislative Auditor Recommendations page.

Appendices

Appendix A: Contractor review | Appendix B: Case manager to client ratios | Appendix C: Applicable statutes | Appendix D: Study questions & methods | Appendix E: Audit authority

Appendix A: Contractor review

JLARC staff contracted with the Institute on Community Integration (ICI) at the University of Minnesota to:

• Review research-based best practices related to the processes developmental disabilities agencies use to determine eligibility and services.
• Review practices from other states.
• Collect feedback from DDA clients, their representatives, and DDA staff.

Best practices and practices from other states

ICI conducted a systematic review of published peer-reviewed and gray literature focused on the following topics:

• Characteristics of state Home and Community Based Services (HCBS) waiver programs.
• Approaches states use to determine eligibility and service needs.
• The impact of those approaches on service recipients.

ICI also interviewed developmental disability agency staff from three comparison states: Oregon, Colorado, and Pennsylvania. ICI and JLARC selected these states based on their HCBS waiver programs, demographic similarities to Washington, and each state's degree of racial/ethnic diversity.

Feedback from DDA clients and their representatives: surveys, interviews, and focus groups

Feedback from DDA clients, their representatives, and DDA staff were primarily analyzed using thematic analysis, which is the coding of responses using themes and patterns. This approach allowed ICI to identify and understand the challenges and successes of DDA's current processes.

ICI's survey of DDA clients and representatives

ICI administered a three-round survey to DDA clients and their representatives via the web between February 28, 2024, and May 29, 2024. The survey was provided in English, Arabic, Chinese, Hindi, Cambodian, Korean, Russian, Somali, Spanish, Tagalog, Ukrainian, and Vietnamese. JLARC and ICI sent outreach emails and reminders encouraging survey completion.

Information in the JLARC report about client experiences comes primarily from the first survey and ICI interviews. The first survey was approximately 23 questions and asked participants about their experiences going through DDA's eligibility and service determination process. It also included demographic questions and four Likert scale questions, asking people to rank various parts of the process from very poor to very good.

Of the 21,407 people contacted, 421 completed the first survey. All three DDA regions were represented in the survey. A larger proportion of women and client representatives participated in the survey compared to the sample.

The second and third surveys were used primarily to confirm results from the first survey. The second survey asked people to rate various themes and challenges derived from the first survey. The third survey asked people to prioritize the importance of making improvements to the key issues identified in the second survey.

Interviews and focus groups

ICI conducted interviews and focus groups with a subsample of people who responded to the survey. The samples were developed using a stratified random sampling approach.

ICI interviewed 48 people. ICI administered the interviews via Zoom or in-person depending on the interviewee's preference between April 25, 2024, and June 6, 2024. Each interview lasted about 30-35 minutes, and each interviewee was asked the same list of questions. ICI asked about their experience:

• Filling out DDA's initial application and how long it took to complete and receive a determination.
• Going through the assessment process, how long the assessment took, and whether case managers were responsive to clients' needs.
• Accessing services and the extent to which case managers were able to provide guidance.

ICI conducted eight focus groups with 28 people. The focus groups were conducted via Zoom from April 30, 2024, to May 17, 2024. Each focus group lasted about two hours and had a conversational structure. Participants were asked to:

• Identify areas of the DDA eligibility and service determination process where improvements are most needed.
• Prioritize changes that need to occur.
• Develop recommendations for ways in which improvement can be made.

DDA staff survey

ICI administered a web-based survey to DDA case managers and supervisors over four weeks beginning May 9, 2024. ICI sent outreach emails and reminders, and DDA management was notified of the survey before it was sent out. In total, the survey had 37 questions split between two distinct paths:

1. Questions that focused on the assistance case managers provide to clients going through the application process.
2. Questions focused on the assessment and ongoing case management.

Of the 793 case managers and supervisors emailed, ICI received 102 responses. Eleven were case managers responding to (1), the questions about the application process. The majority (68) of responses came from case managers responding to (2), the questions about assessment and ongoing case management. The remaining respondents were either supervisory staff or did not indicate their role.

DDA staff focus groups

ICI conducted three focus groups with a total of eight case managers. Focus groups were developed using a stratified random sampling approach drawn from the sample of 102 case managers who responded to the survey. Participants were asked to discuss the same topics as discussed in client focus groups.

Appendix B: Case manager to client ratios

Appendix C: Applicable statutes

Title 71A RCW – Developmental Disabilities

Appendix D: Study questions

This study aimed to answer the following questions, which were presented to JLARC in July 2023 (view here).

1. What are DDA's processes for determining eligibility, assessing needs, and ensuring that eligible individuals can access services?
   1. Are the processes user-friendly?
   2. To what degree does DDA implement its processes in a consistent, equitable, culturally responsive, and efficient way?
   3. How do DDA's processes compare to those in other states?
2. How does DDA manage the list of individuals who are waiting for services?
   1. What are their characteristics and needs? Do they differ from those who receive service?
   2. What factors affect the number of individuals waiting for services?
3. How does DDA determine staffing levels for client intake and case management?
   1. What is DDA's approach to hiring, retaining, and training staff to do this work?
   2. Is DDA's approach consistent with its goals to promote diversity, equity, and inclusion in its workplace and public outreach?

Methods

The methodology JLARC staff use when conducting analyses is tailored to the scope of each study, but generally includes the following:

• Interviews with stakeholders, agency representatives, and other relevant organizations or individuals.
• Site visits to entities that are under review.
• Document reviews, including applicable laws and regulations, agency policies and procedures pertaining to study objectives, and published reports, audits or studies on relevant topics.
• Data analysis, which may include data collected by agencies and/or data compiled by JLARC staff. Data collection sometimes involves surveys or focus groups.
• Consultation with experts when warranted. JLARC staff consult with technical experts when necessary to plan our work, to obtain specialized analysis from experts in the field, and to verify results.

The methods used in this study were conducted in accordance with Generally Accepted Government Auditing Standards.

More details about specific methods related to individual study objectives are described in the body of the report under the report details tab or in technical appendices.

Appendix E: Audit Authority

The Joint Legislative Audit and Review Committee (JLARC) works to make state government operations more efficient and effective. The Committee is comprised of an equal number of House members and Senators, Democrats and Republicans.

JLARC's nonpartisan staff auditors, under the direction of the Legislative Auditor, conduct performance audits, program evaluations, sunset reviews, and other analyses assigned by the Legislature and the Committee.

The statutory authority for JLARC, established in Chapter 44.28 RCW, requires the Legislative Auditor to ensure that JLARC studies are conducted in accordance with Generally Accepted Government Auditing Standards, as applicable to the scope of the audit. This study was conducted in accordance with those applicable standards. Those standards require auditors to plan and perform audits to obtain sufficient, appropriate evidence to provide a reasonable basis for findings and conclusions based on the audit objectives. The evidence obtained for this JLARC report provides a reasonable basis for the enclosed findings and conclusions, and any exceptions to the application of audit standards have been explicitly disclosed in the body of this report.

JLARC members on publication date