This guest post from Jennifer Wagner, Senior Policy Analyst at the Center on Budget and Policy Priorities, is part of an ongoing series presenting lessons from the Integrated Benefits Initiative, which uses human-centered design and modern technology to improve access to SNAP, Medicaid, and other safety net programs. Through five small-scale pilots around the country, Code for America, Nava PBC, and the Center on Budget and Policy Priorities are partnering to bring best-in-class design, technical, product, and policy expertise to show how states can build human-centered services fit for the digital age. This series provides practical guidance to state officials and others on creating and sustaining user-centered services in the social safety net.
As state and county health and human services agencies seek to modernize and improve communications with their clients, many are considering text messaging to supplement existing means of communication. Text messages are commonly used, can reach clients more quickly than traditional mail, and can notify clients of interview times, remind them about needed verification documents, and even collect information. Done well, text messaging can enhance existing forms of communication and improve the delivery of critical safety net programs. To take full advantage of this communication channel, agencies would do well to identify effective uses for text messages, obtain opt-ins from clients, and navigate privacy and security concerns.
How Can Text Messaging Improve Communication?
Health and human services agencies correspond with clients to provide interview times, request documents to verify eligibility, and send notices of changes or other actions concerning their benefits. Traditionally, they do so via the postal service, but traditional mail takes multiple days in transit and may never reach the client due to inaccurate addresses or unreliable mailboxes. As a result, many clients don’t receive important notices and lose access to critical benefit programs.
“I would prefer [text message reminders] because I always have my phone on me.”
Low-income families increasingly rely on cell phones for communication. Over 90 percent of adults with incomes below $30,000 own a cellphone.¹ And smartphone owners use text messaging more frequently than any other feature or app.² The Agriculture Department’s Food and Nutrition Service, which oversees the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), recognizes that mobile technology — including text messaging — allows states to “provide better service and more readily reach populations that lack access to a personal computer, enhancing access for those who would otherwise be limited in their ability to access information and complete the certification process.”³
Text messaging offers functional advantages over other forms of communication: text messages are nearly instantaneous, visual, create an easy-to-reference record, and can be read at the recipient’s convenience. In the context of safety net programs, text messaging provides a means to quickly notify clients about important information about their benefits or direct them to take action in an online account. While it is best used in addition to, rather than as a replacement for, traditional means of communication, it can shorten response times and increase the likelihood that clients receive critical information.
Using Text Messaging for One-Way Communication
Agencies may wish to use text messaging for one-way communication — that is, sending information to the client without expecting a reply. This approach is most effective for short messages giving clients critical information or notifying them that action is required, such as:
· Notice of a SNAP or WIC appointment;
· Reminder that verification documents are due;
· Alert that a new notice is available in a client’s online account;⁴ or
· Information about how to renew expiring benefits.
Code for America conducted user research with clients of various benefit programs that confirms client interest in using text messaging to communicate with agencies. The majority of clients in one state said they would opt in to receive text message reminders. In general, clients wanted text messages at critical points in their case, including appointment reminders with specific details and confirmation that they had submitted the proper verification documents.
“[With] the text messages, you’re getting it right there, you’re informed of it immediately.”
Using Text Messaging for Two-Way Communication
Agencies may also wish to use text messaging for two-way communication with clients, allowing the agency to both send and receive information. Agencies could use this for gathering information from a client or for a conversation between a caseworker and client. For example:
· Clients could report a change to the agency, such as a new address;
· Clients could submit required verification documents to the agency, such as a letter from an employer;
· Clients could request that the agency reschedule an appointment;
· Caseworkers could quickly notify clients that additional documents are needed to determine eligibility (for example, if the client submitted the wrong pay stubs); or
· Caseworkers could ask questions or request clarification from clients on unclear information.
Evaluating the Effectiveness of Text Messaging
Agencies may wish to deploy text messaging gradually to test the most effective timing and content. They could identify key points in the eligibility process and measure outcomes before and after implementing text messaging or between different groups. For example, an agency could send a text message reminding Medicaid beneficiaries that they need to recertify and then compare the recertification rates:
· Before and after sending the reminder;
· Between groups that received reminders 30 days, 15 days, or 5 days before the recertification was due; or
· Between groups that received different reminder messages.⁵
Key Considerations for Text Messaging
While text messaging is routine for many individuals, it is newer to health and human services agencies. Agencies must navigate various processes and policies to ensure their messages are effective and the client’s privacy is protected.⁶ They should consult with their legal departments to ensure their texting policy conforms to federal and state laws and regulations.
Obtaining Clients’ Consent (Opting In)
Before sending any text messages, an agency must obtain the client’s consent. Through an application or renewal form or via an online account, the agency can give clients the opportunity to “opt in” to receiving text messages. The opt-in message should:
· Identify which agency will send the messages;
· State the general content of the communications (e.g., “Important notifications about your benefits”);
· Mention the frequency of the messages;
· Disclose that message and data rates may apply for receiving text messages;⁷ and
· Give clients a means to “opt out” of receiving messages in the future.
Sample Opt-In Language
For one-way texting: The [state SNAP agency] invites you to receive communications through text messages with important notifications about your benefits. If you choose to participate, you will receive up to 5 messages per month. Standard messaging and data rates may apply. Participation is optional, and you may stop the messages at any time by contacting a caseworker or through your online account. Do you want to receive important notifications through text messaging?
For two-way texting: The [state health agency] invites you to communicate through text messages with your caseworker about verification documents that you’ll need to submit for your case. While [state health agency] takes all the proper precautions to safeguard your personal information within its systems, text and photo messages may be read by anyone with access to your phone or by entities with access to your mobile provider network. Standard messaging and data rates may apply. Participation is optional, and you may stop the messages at any time by contacting a caseworker or through your online account. Do you want to communicate with your caseworker through text messages?
Protecting Clients’ Privacy
Agencies must take measures to protect client privacy wherever possible. People other than the client can read text messages if they have access to the client’s cellphone or see a message in passing. To protect client privacy, agencies should keep text messages short and omit unnecessary private information. For example, the message “Your benefits are about to expire! Log in to www.benefits.state to complete your renewal or call 1–800-XXX-XXXX for more information” conveys the required information with no unnecessary personal information.
Informing Clients About Security
When engaging in two-way communication with clients, agencies should inform them that text messaging is not a secure means of communication and make sure they acknowledge the potential (though small) risk associated with sending information via text message. This may be a minor concern if a client is trying to reschedule an appointment or answer a simple question about their household situation, but it is more serious if a client is transmitting documents to the agency that may contain sensitive information.
Case Study: Michigan Department of Health and Human Services
A recent pilot project in Michigan showed the potential for two-way text messaging in safety net programs. Two nonprofits, Code for America and Civilla, worked with the Michigan Department of Health and Human Services (MDHHS) to test how two-way text messaging might help both clients and caseworkers.
In a first-of-its-kind pilot, four caseworkers used an off-the-shelf tool to help 69 clients submit needed verification documents by text message. Caseworkers sent personalized text messages to clients, and clients responded by asking questions and submitting photos of the required paperwork. While small in scope, the pilot offered helpful takeaways for agencies interested in text messaging:
· Having a flexible communication channel benefits both clients and caseworkers;
· Camera phones make it easier for clients to submit documents;
· Specific, responsive guidance from caseworkers improves the accuracy of document submission;
· Faster feedback loops allow errors to be resolved in hours, instead of days or weeks; and
· Text messaging is not for everyone. The opt-in rate was 51 percent, with some clients preferring in-person interactions or expressing concerns about submitting paperwork by phone.
Outcomes of the pilot were promising: for cases involved in the pilot, the average time needed to reach an eligibility determination fell from 13 to 10 days and the approval rate rose from 53 to 67 percent. While the denial rate due to missing verification documents stayed the same (43 percent), two caseworkers had no procedural denials during the pilot.
“It would cut down on my work if I could text residents about their missing documents,” one caseworker explained; “I wouldn’t have to play phone tag or send a letter that would be irrelevant by the time it gets to them.” Another caseworker noted, “Residents come into the office all the time because they are confused about the letters MDHHS sends out. Text messaging would be so much better — it’s simple, understandable, fast, and to the point!”
New Digital Tools Guide Can Help Agencies Implement Text Messaging
Health and human service agencies likely have varying degrees of experience with customer-facing digital tools such as texting platforms; by working carefully with potential vendors, involving staff and clients in planning and implementation, and assessing results, agencies can use texting effectively to improve communication between caseworkers and clients. The guide “Launching New Digital Tools for WIC Participants” (www.cbpp.org/wicparticipanttechnology), from Social Interest Solutions, the National WIC Association, and the Center on Budget and Policy Priorities, can help agencies interested in implementing text messaging navigate the process. While primarily designed for agencies considering using customer-facing digital tools in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), much of it is also relevant to other programs.
The guide, which includes a checklist for drafting a request for proposals, can help agencies: evaluate the important choices to consider before purchasing digital tools; develop questions to discuss within the agency and with potential vendors; look for key features to ensure that digital tools are user-friendly for clients; incorporate digital tools into program operations; utilize data to improve digital tools over time; and communicate to vendors the types of functionality and tools that would help clients.
 Pew Research Center, “Mobile Fact Sheet,” February 5, 2018, http://www.pewinternet.org/fact-sheet/mobile/.
 Aaron Smith, “U.S. Smartphone Use in 2015,” Pew Research Center, April 1, 2015, https://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
 United States Department of Agriculture, State Options Report, 14th Edition, May 31, 2018, https://fns-prod.azureedge.net/sites/default/files/snap/14-State-Options.pdf.
 The Food and Nutrition Service allows agencies to send email and text alerts about new notices but sending text messages alone requires a waiver. https://fns-prod.azureedge.net/sites/default/files/snap/Memo-Electronic-Notice-and-Other-Options-11317.pdf.
 For example, New York City reduced the failure-to-appear rate for recipients of summonses by 26 percent by testing different reminder messages to “nudge” them into attending court appearances. ideas42, “New text message reminders for summons recipients improves attendance in court and dramatically cuts warrants,” http://www.ideas42.org/new-text-message-reminders-summons-recipients-improves-attendance-court-dramatically-cuts-warrants/.
 For more information and examples, see King County (WA), “SMS text messaging for Public Health communication,” www.kingcounty.gov/texting.
 Many clients participating in programs like SNAP and Medicaid have subsidized cellphone service through the Lifeline program. Though most plans have a limited amount of data, many include unlimited text messages. For more information about participating companies in your area, see https://www.lifelinesupport.org/ls/default.aspx.