1. Eligibility Screening and Initial
Application to Social Services
System
Business Model and System Design
OCTOBER 1996
Pacific
Management
and Research
Associates
____________________________________1721 Second Street, Suite 203
Sacramento, California 95814
(916) 448-9038
PMRA

3. Eligibility Screening
and Initial Application
to Social Services
System
Business Model and System Alternatives
Presented To:
Oregon Pathways
Clackamas County Department of Human Services
1024 Main Street
Oregon City, OR 97045
(503) 650-3567 Voice / (503) 655-8677 FAX
Presented By:
Pacific Management and Research Associates
1721 Second Street, Suite 203
Sacramento, California 95814
(916) 448-9038 Voice / (916) 448-6848 FAX / (916) 448-5376 BBS
October 8, 1996

5. Oregon Pathways i
Pacific Management and Research Associates December 14, 2015
Letter of Transmittal
The Oregon Department of Human
Resources and Clackamas County are
pleased to release this technical feasibility
study for Oregon Pathways. This venture
was part of a project intended to test
concepts for the integration of social
services. Simply put, our goal was to make
it easier for people who need services to get
them and to redirect resources now used for
client processing to more direct services.
An impressive group of managers
responsible for service delivery in
Clackamas County came together for an
intensive eighteen months of problem
solving and research. The agencies
represented included the Oregon State
Employment Department, North Clackamas
School District, Social Security
Administration, Adult and Family Services,
and Clackamas Department of Human
Services. The Clackamas County
Department of Human Services includes
Public Health, Social Services, Mental
Health, Housing Authority, Community
Development, Community Corrections,
Employment Training and Business
Services (JTPA).
All the agencies committed to this
effort recognized that existing accountability,
eligibility screening and data collection were
necessary for direct service funding to
continue. However, they were also
committed to working together to reduce
unnecessary duplication and to use
technology to collaboratively redesign the
way people access services. This redesign
initiative was holistic. It focused on the
entire service milieu without regard to
program definition or jurisdictional control.
We believe that the Oregon
Pathways initiative will demonstrate how the
delivery of government services can be
dramatically improved.
Pacific Management and Research
Associates responded to our challenge to
develop a technical feasibility study. Their
task was to evaluate and describe technical
alternatives, provide design specifications
for required software and hardware,
estimate the costs of development and
implementation and conduct a cost analysis.
The work of Fred Best, Bob Herguth, Cy
Welch and Bernadette Dawson has been
exemplary. The Oregon Pathways Project
has been on a fast tract since its inception.
PMRA kept up the pace and, through this
report, have positioned us to begin the
reengineering process.
This report clearly shows that
implementation of Oregon Pathways is
feasible, and that it will be cost effective.
What the report cannot impart is the
unprecedented demonstration of
camaraderie, coordination and cooperation
that resulted from this initiative. Nor can it
fully capture how the magic of information
technology can aid and empower people.
With great pleasure, we present the
Business Model and System Alternatives for
Oregon Pathways.
Project Managers: Jono Hildner, Clackamas County Department of Human Services
Gary Potter, State of Oregon Department of Human Resources
Michele Wallace, State of Oregon, Adult and Family Services
Project Coordinator: Deborah Helgerson, Clackamas Department of Human Services

7. Oregon Pathways iii
Pacific Management and Research Associates December 14, 2015
Oregon Pathways Steering Groups
Design Team
Tim Carman
Deputy Superintendent
North Clackamas School
District
Gary DiCenzo
Director
Housing Authority and
Community Development
Terry Gassaway
Director
Clackamas County
Community Corrections
Barbara Gasuen
Assistant Director
Oregon City Office,
Employment Department
Deborah Helgerson
Project Coordinator
Pathways Project
Jono Hildner
Director
Department of Human
Services
Ron Lajoy
Assistant Director
Mental Health and Clinical
Services
John Mullin
Director
Clackamas County Social
Services
Gary Potter
Project Coordinator
Pioneer Center of Adult
and Family Services
Dell Smith
Director
Employment, Training and
Business Services
Guy Super
District Manager
Social Security
Administration
Tom Troxel
Director
Public Health
Michele Wallace
District Manager
Adult and Family Service,
Clackamas District
Jan Wolfe
Facilitator
Olympic Performance,
Inc.
Detail Team
Lennie Bjornsen
Director
Office of Children and
Families
Diane Chown
Employer Relations
Oregon City Office,
Employment Service
Diane Gissel
Office Specialist I
Clackamas County Social
Services
Deborah Helgerson
Project Coordinator
Pathways Project
Barbara Hopson
Administrative Analyst
Public Health
Patty Huntley
Program Manager
Clackamas County Social
Service
Tim Kopet
Supervising Psychologist
Mental Health
Nancy Latini
Director
North Clackamas County
School District
Michael Lee
Services Coordinator
Employment, Training and
Business Services
John Margaronis
Assistant Administrator
State Department of
Human Resources
Sue Manning
Service Representative
Oregon City Office,
Employment Service
Roger Martin
Service Coordinator
Employment, Training and
Business Services
Karin Morey
Parole and Probation
Clackamas County
Community Corrections
Jon Pierce
Human Resources
Specialist, Adult and
Family Services
Anita Pixley
Services Supervisor
Clackamas County
Housing Authority
Will Reinhart
Operations Manager
Adult and Family Services
Yolanda Stewart
Social Security Liaison
Clackamas County Social
Services
Technical Team
Deborah Helgerson
Project Coordinator
Pathways Project
Jono Hildner
Director
Department of Human
Services
Ward Kent
Assistant Director of Data
Processing, Department
of Human Resources
Grant Norlin
LAN Administrator
Employment, Training and
Business Services
Wilson Orso
Systems Analyst, State
Job Training Partnership
Administration
Kelly Otto
Information Systems
Liaison, Oregon City
Employment Department
Gary Potter
Project Coordinator
Pioneer Center of Adult
and Family Services
Ros Samnang
Project Leader, Service
Integration, Department of
Human Resources
Ed Seufert
Systems Administrator
Clackamas County
Information Services
Terry Souza
Oregon Employment
Department
Pacific Management and Research Associates
Fred Best
President
Bernadette Dawson
Vice President
Robert Herguth
Systems Analyst
Cyrus Welch
Senior Programmer

8. iv Cover Sheets
Pacific Management and Research Associates December 14, 2015
Acknowledgments
Appreciation is expressed to the following people for their generous advice, assistance and
information: his paper was prepared with advice and information from many people. Pacific
Management and Research Associates appreciates the assistance provided so generously
from the following persons.
Lennie Bjornsen, Office of Children and
Families
Tim Carman, Ph.D. North Clackamas
School District
Diane Chown, Oregon City Employment
Department
Jan Cox, Clackamas County Department
of Human Services
Terry Gassaway, Clackamas County
Community Corrections
Gary DiCenzo, Housing Authority ands
Community Development
Diane Gissel, Clackamas County Social
Services
Barbara Gasuen, Oregon City
Office-Employment Department
Tammie Fisher, Employment, Training
and Business Services
Ward Kent, Adult and Family Services,
Clackamas Branch
Mary K. Holder, Clackamas County
Department of Human Services
Barbara Hopson, Public Health
Patty Huntley, Clackamas County Social
Services
Tim Kopet, Ph.D., Mental Health
Ron Lajoy, Ph.D., Mental Health
Nancy Latini, Ph.D., North Clackamas
County School District
Michael Lee, Employment Training and
Business Service
Gloria Lewton, Clackamas County
Department of Human Services
John Margaronis, State Department of
Human Resources
Sue Manning, Oregon City Employment
Department
Roger Martin, Employment Training and
Business Services
Karin Morey, Clackamas County
Community Corrections
John Mullin, Clackamas County Social
Services
Grant Norlin, Employment, Training and
Business Services
Kelly Otto, Oregon Employment
Department
Pam Peterson, Clackamas County
Department of Human Services
Toni Peterson, Department of Human
Resources
Jon Pierce, Adult and Family Services,
Clackamas Branch
Anita L. Pixley, Clackamas County
Housing Authority
Will Reinhart, Adult and Family Services,
Clackamas Branch
Ros Samnang, Oregon Department of
Human Resources
Ed Seufert, Clackamas County
Information Services
Linda Slama, Clackamas County
Department of Human Services
Dell Smith, Employment, Training and
Business Services
Terry Souza, Oregon Employment
Department
Yolanda Stewart, Clackamas County
Social Services
Guy Super, U.S. Department of Health
and Human Services
Tom Troxel, Clackamas County Public
Health
Jan Wolfe, Olympic Performance, Inc.
The contents of this paper do not necessarily reflect the views of any of these individuals or
the agencies they represent

9. Oregon Pathways v
Pacific Management and Research Associates December 14, 2015
Table of Contents
COVER SHEETS
Letter of Transmittal........................................................................................................i
Oregon Pathways Steering Groups..............................................................................iii
Acknowledgments.........................................................................................................iv
Table of Contents ...........................................................................................................v
1. INTRODUCTION AND BACKGROUND ............................................................... 1
1. History.........................................................................................................................1
2. Pathways to the Future ..............................................................................................3
The Social Forces Behind Pathways............................................................................................................3
Linkage to Other Policy Initiatives ................................................................................................................4
3. Preview of Report .......................................................................................................5
2. BUSINESS MODEL AND SYSTEM OVERVIEW.................................................. 7
1. Problem Statement.....................................................................................................7
2. Mission and Objectives..............................................................................................8
Mission Statement........................................................................................................................................8
Operational Objectives .................................................................................................................................8
3. Overview of Proposed System ................................................................................10
4. Linking System Goals and Functions .....................................................................13
3. EVALUATION OF ALTERNATIVES ................................................................... 21
1. Evaluation Criteria....................................................................................................21
2. Parameters of the Pathways System.......................................................................22
3. Isolation of Alternative Approaches........................................................................23
Defining Issues...........................................................................................................................................23
Generation of Alternatives..........................................................................................................................25
Definition of Components ...........................................................................................................................26
Assumptions and Undefined Conditions.....................................................................................................27
4. Review and Evaluation of Alternatives ...................................................................28
Alternative 1: Central Processing and Data Storage ..................................................................................29
Alternative 2: Central Processing and No Data Storage.............................................................................31
Alternative 3: Central Eligibility Screening and Data Storage with Remote Referral Processing................34
Alternative 4: Central Eligibility Screening, Remote Referral Processing and No Data Storage.................36
Alternative 5: Remote Eligibility with Central Referral Processing and Data Storage.................................39
Alternative 6: Remote Eligibility Screening, Central Referral Processing and No Data Storage.................41
Alternative 7: Remote Eligibility Screening and Referral Processing with Central Data Storage................44
Alternative 8: Remote Eligibility Screening and Referral Processing with No Data Storage.......................46
Alternative 9: Agency-Based Eligibility Screening with Central Referral Processing and Data Storage .....49
Alternative 10: Agency-Based Eligibility Screening, Central Referral Processing and No Data Storage....51
Alternative 11: Agency-Based Eligibility Screening, Remote Referral Processing, and Data Storage .......54
Alternative 12: Agency-Based Eligibility Screening, Remote Referral Processing, and No Data Storage..57
5. Comparative Evaluation of Alternatives .................................................................60
4. TEST OF PROTOTYPE....................................................................................... 63
1. Potential for “User Friendliness” ............................................................................63
Initial Access Screens ................................................................................................................................63
Entry of Client ID Information .....................................................................................................................65
Get Best Source Data and Eligibility Screening..........................................................................................66

10. vi Cover Sheets
Pacific Management and Research Associates December 14, 2015
Review Programs for Which Client is Eligible.............................................................................................68
Process New Client or Exit.........................................................................................................................69
2. Implications for System Design...............................................................................69
5. COST ANALYSIS................................................................................................ 71
1. Framework for Cost Analysis ..................................................................................71
2. Costs of Implementation and Maintenance ............................................................72
Costs of Development and Implementation................................................................................................73
Maintenance Costs.....................................................................................................................................73
3. Economic Benefits ...................................................................................................75
Return on Investment .................................................................................................................................75
Lower Processing Costs.............................................................................................................................76
Reduced Paper Forms and Records ..........................................................................................................84
4. Break Even Analysis ................................................................................................86
5. Replication Costs .....................................................................................................87
6. SYSTEM DESIGN ............................................................................................... 89
1. Design Parameters ...................................................................................................89
2. Alternative Designs ..................................................................................................90
Discussion of Alternatives ..........................................................................................................................91
3. Design Specification ................................................................................................98
Scope of Design.......................................................................................................................................100
System Narrative......................................................................................................................................100
Definition of Components .........................................................................................................................102
Module Design Narrative..........................................................................................................................106
Standards and Conventions .....................................................................................................................116
Menu Specification...................................................................................................................................118
Input Specifications ..................................................................................................................................118
Output Specifications ...............................................................................................................................118
Technical Specifications...........................................................................................................................119
4. System Controls .....................................................................................................122
User Input.................................................................................................................................................122
Disaster Recovery....................................................................................................................................122
Security ....................................................................................................................................................123
Privacy......................................................................................................................................................124
7. MILESTONES FOR IMPLEMENTATION.......................................................... 129
1. Overview and Timetable.........................................................................................129
2. Elaboration of Tasks and Milestones....................................................................131
Planning and Review................................................................................................................................131
System Development ...............................................................................................................................132
Installation and Training ...........................................................................................................................138
Management and Accounting...................................................................................................................140
3. Project Integration and Prioritization ....................................................................140
Prerequisite Analysis................................................................................................................................140
8. APPENDICES.................................................................................................... 143
A1. Principles and Objectives of Oregon Pathways.................................................144
A2. Detailed List of Pathways Goals and Objectives ...............................................145
A3. System Outputs....................................................................................................151
A4. Summary of System Functions...........................................................................156

11. Oregon Pathways vii
Pacific Management and Research Associates December 14, 2015
A5. Oregon Pathways Agencies and Programs .......................................................157
A6. Privacy Protection Agreement ............................................................................159
A7. Eligibility Screening Flowcharts .........................................................................162
A8. Data Matrices........................................................................................................183
9. TABLE OF EXHIBITS ....................................................................................... 195

13. Oregon Pathways Page 1
Pacific Management and Research Associates December 14, 2015
Chapter 1
Introduction and Background
This report presents a technical plan for the development and
implementation of an integrated eligibility screening system; the first
component of the Oregon Pathways initiative. The report presents goals
and objectives of the system, evaluates practical alternatives, and
presents a design, cost justification and implementation plan.
The Oregon Pathways initiative strives to change the way public
agencies deliver services to clients. Oregon Pathways is applying
cross-agency collaboration, information technology and service
integration to improve the quality and efficiency of service delivery.
This chapter provides a history of the Pathways initiative,
summarizes the social and policy context of the project, and
previews the overall contents of this report.
1. History
Oregon Pathways is the result of a multi-year state-local
collaboration to improve the efficiency and accessibility of human
services.
The first stages of this initiative began in 1991, with a state
program that awarded grants to local government for planning
innovative approaches to service integration. Clackamas County
applied for and received one of these grants for the purpose of
developing an interactive service information and referral (I&R)
system. After completing this project, Clackamas County received
a second grant to improve access to services by streamlining
eligibility determination.
In late 1993, Clackamas County established a staff for
Pathways, then worked with state and federal agencies to setup a
“Design Team” composed of chief executives from twelve human
service agencies. Over the next several months, this team
engaged in weekly meetings to explore “how to design and
implement an automated system to integrate access to the total
spectrum of services supporting the self-sufficiency of families.”
By mid-1994, these meetings resulted in agreements on the
principles and approaches for creating a common access eligibility
screening system, and established common understanding and

14. 2 Introduction and Background
Pacific Management and Research Associates December 14, 2015
cooperative working relations among Participating Agencies
(Appendix 1).
During the second half of 1994, the Design Team began
focusing attention toward implementation preparation. A “Detail
Team“ was setup to review and specify detail about agency
inner-workings related to Pathways. Among other things, this
Detail Team identified the privacy concerns and procedures,
existing agency equipment and resources, data and procedures
needed to integrate eligibility screening for Participating Agencies.
During this time, the Design Team made arrangements to procure
technical planning support and establish a “Technical Team” to
guide systems design. The fourth team, the User Team, was
organized in the second half of 1995 to integrate feedback about
the Pathways concept from the standpoint of line staff and
managers.
Oregon Pathways has moved forward through a highly
participatory, multi-tiered planning process. As noted above, this
process was anchored in four planning teams:
 Design Team. The vision of the Oregon Pathways
initiative is guided by the Design Team. This team consists
of agency heads from county, state and federal service
providers. It provides the conceptual foundation for the
Oregon Pathways initiative.
 Detail Team. Detail team members provide practical
information, through research and experience, from their
respective agencies to fill in and develop the foundation laid
by the design team.
 Technical Team. Technical team members bring the
information technology resources and experience
necessary to guide the design, development, and
implementation of Oregon Pathways information systems.
 UserTeam. User team members provide feedback on
system software revisions, formulate staff training plans,
and ensure that information about staff interactions with the
system are fed back into the development process.
During the first half of 1995, these teams worked to produce the
technical blueprint for Oregon Pathways that is summarized in this
report (see page iii for the membership of these teams).
Pathways represents a ground breaking effort to use open
participation and technology to reduce the confusion, inefficiency
and polarization that confounds efforts to improve and
operationalize cross-agency cooperation. Its sustained success
and forward motion can be attributed to three key factors. First,
the process through which Pathways was conceived and
developed has been open, meticulously balanced, and inclusive.
It has involved all major human resource agencies and levels of
Oregon
Pathways has
moved forward
through a highly
participatory,
multi-tiered
planning
process.

15. Oregon Pathways Page 3
Pacific Management and Research Associates December 14, 2015
staff in a process that has continually fostered trust and buy-in
among participants. Second, it has been favored with agency
decision makers who understand the potential of information
technology and are willing to seek new solutions to improving
government services, and are prepared to take risks to pursue that
purpose. Third, Pathways has focused on using participatory
planning and technology to increase communications and ease the
task of developing functional service integration. It has not sought
to change, consolidate, or control participating agencies. Rather,
it has sought to create personal and electronic linkages at the
service level that allow clients, staff and agency managers to freely
share resources and coordinate services.
2. Pathways to the Future
Oregon Pathways is concept that strives to re-engineer processes
that directly affect the way services are provided to clients. It
reflects the changing conditions and needs of our society and
inter-links with other important policy innovations.
The Social Forces Behind Pathways
Oregon Pathways reflects changes that are restructuring all
aspects of our lives and society, and altering the fundamental
assumptions that guide our human services.
American society is well into the process of moving from a
manufacturing-based “industrial era” to a technology and
service-based “information era”.
Among the changes that are emerging from this transition, four
seem to be well established. First, our production processes are
moving increasingly to commodities and services that are
customized to individual needs. Second, information technology is
allowing our economic and social institutions to become
increasingly decentralized. Third, the ways we organize our
society are becoming less bureaucratic and more fluid. Fourth,
productive equipment and resources are becoming increasingly
accessible for direct individual use (Exhibit 1.1).
Exhibit 1.1
INFORMATION ERA
TRENDS
The services and products
of the future - whether they
be privately or publicly
generated - will be
increasingly
client-centered.

16. 4 Introduction and Background
Pacific Management and Research Associates December 14, 2015
 Individualized Products and Services
 Computer Assisted Design and Manufacturing (CAD/CAM)
 Small Batch Production Runs and Flexible Manufacturing
 Direct Access Technology
 Non-Traditional Education, Individual Study
 Individual Service Strategies
 Decentralization
 Telecommuting
 “Virtual Organization” or “Hollow Corporation”
 Schools without Walls
 Front-Line Decision Making
 Open Access Information Services (Internet, AOL, Prodigy)
 Flexible Organization
 Out-Sourcing or Sub-Contracting
 Project-Oriented Organization or ”Adhocracy”
 Temporary Placement Agencies or Renting Employees
 Corporate “Downsizing” or ”Rightsizing”
 Increased Self-Employment
 “Just-in-Time” Inventory
 Leasing Versus Ownership
 Personal Capitalization
 Miniaturization and Transportability (Microchips, Cellular Phones)
 Common Access Technology (ATMs, TV Courses, Video Tapes)
 Economic Affordability of Equipment (PCs, VCRs, Laser Printers)
 Electronic Money and Credit (Credit Cards, Training Vouchers)
Among the implications of these four trends, one stands out.
We are moving away from an era where individuals gathered
around centrally located resources - schools, factories, hospitals -
that were based upon the need to organize clients and workers
around heavy equipment. In its place, we are moving into an era
where equipment, resources and services are clustered around the
individual. The services and products of the future - whether they
be privately or publicly generated - will be increasingly
client-centered.
Pathways represents a ground-breaking initiative to integrate
government services to meet individual needs, and to empower
individuals with the information and choices needed to access the
services that best meet their needs.
Linkage to Other Policy Initiatives
Government agencies at all levels are focusing increasingly on the
issues of improving quality and individualization of services,
enhancing access and personal choice, increasing cross-agency
collaboration and service integration, and applying outcome
oriented accountability.
Oregon has been at the forefront of many of these initiatives.
At the state and local level, Oregon has been a pacesetter in
implementing federal reforms, and has been the originator of a
number of policy innovations (Exhibit 1.2).

17. Oregon Pathways Page 5
Pacific Management and Research Associates December 14, 2015
 Quality and Individualization of Services
 Oregon Transition, Referral, Client Self-Sufficiency System (TRCS)
 The Oregon Option
 DOL Displaced Worker Training Accounts
 Access and Personal Choice
 Clackamas County Prism Information and Referral System
 Distributed Oregon on-line Public Health Information (DOLPHIN)
 Employment Service Kiosks
 Faces and Hermisten Projects
 Telecommunication Information Infrastructure Assistance Program
 Cross-Agency Collaboration and Service Integration
 Federal Department of Labor “One-Stop Shopping” Initiatives
 America 2000 Education Reforms
 Human Resource Investment Councils (HRICs)
 Oregon Service Integration Grants
 Shared Information Systems (SIS)
 Process Automation
 Oregon ACCESS Forms Automation Project
 Outcome Oriented Accountability
 National Performance Review (NPR)
 Oregon Benchmarks
Most notably, state and local governments within Oregon have
been at the forefront of harnessing information technology as a tool
for empowering citizens to access and choose public services that
meet individual needs.
As Oregon Pathways progresses from concept to reality, it will
complement and inter-link with other efforts to re-engineer
government.
3. Preview of Report
The purpose of this report is to outline a design for the initial phase
of the Pathways initiative, which focuses on integrated eligibility
screening across public service providers in Clackamas County.
The proposed system has been designed for Clackamas County
with the intention that the proven design may be implemented
throughout Oregon.
The report will have seven chapters:
[1] Introduction and Background. This chapter provides
background on the history and pertinence of Pathways.
[2] Business Model and System Overview. Chapter 2
specifies the objectives and functions of Pathways.
Exhibit 1.2
PUBLIC INITIATIVES
THAT CAN BE LINKED
TO PATHWAYS
As Oregon Pathways
progresses from concept to
reality, it will complement
and inter-link with other
efforts to re-engineer
government.

18. 6 Introduction and Background
Pacific Management and Research Associates December 14, 2015
[3] Evaluation of Alternatives. This chapter describes and
evaluates alternative approaches to implementing
path-ways.
[4] Test of Prototype Chapter 4 describes the nature and
results of a functional test of the Pathways concept.
[5] Cost Analysis. This chapter specifies the costs of
implementing and maintaining Pathways relative to the
current system of agency-based eligibility screening.
[6] System Design. This chapter provides the design for
development of the Oregon Pathways system.
[7] Milestones for Implementation. The final chapter
outlines a timetable and sequence of activities for
implementation of the first phase of Pathways.
Appendices are attached to the end of this report to provide
more background and elaboration of selected sections and a table
of exhibits is provided for your convenience.

19. Oregon Pathways Page 7
Pacific Management and Research Associates December 14, 2015
Chapter 2
Business Model and System
Overview
This chapter specifies the goals and objectives of the Oregon
Pathways initiative, and outlines prospective functions for the proposed
system.
The purpose of this chapter is to specify goals and functions for
the Oregon Pathways initiative to integrate eligibility screening
across public service providers in Clackamas County. The
proposed system has been designed for Clackamas County with
the intention that the proven design may be implemented across
Oregon.
This chapter focuses on the business model that will be
supported by the Oregon Pathways information system. It has
four sections:
 Problem Statement
 Mission and Goals
 Overview of Proposed System
 Linking System Goals and Functions
These sections provided the conceptual foundation for
identifying alternative approaches and for the development of an
operational model and testable prototype.
1. Problem Statement
From the perspective of a client, finding and receiving human
services in Oregon is a confusing and tiring process. Each agency
has multiple programs, each with its own intake and eligibility
requirements, appointment schedules, case backlogs, and
verification requirements. The client must struggle through each
redundant process until the agency’s requirements are met and
services can be delivered. The door that the client walks through
first is likely to be the agency that the client accesses services from,
for better or worse.
From the standpoint of a public human service provider, the
view is not any better. The agency must navigate a maze of

20. 8 Business Model and System Overview
Pacific Management and Research Associates December 14, 2015
crisscrossing and sometimes conflicting federal, state, and local
intake, eligibility, and verification guidelines before services can be
delivered. The result is slow, ineffective, inefficient service
delivery as well as increased error rates, increased costs, and
potential system abuses.
2. Mission and Objectives
The Oregon Pathways initiative has developed out of several years
of inter-agency discussion among the social service agencies of
Clackamas County and the State of Oregon (Appendix 5). The
following sections on the Mission Statement and Oregon Pathways
goals and objectives have evolved from these inter-agency
discussions.
Mission Statement
The Oregon Pathways System will use information technology
and cross-agency coordination to streamline application and
eligibility screening processes, shift staff from “paperwork” to client
service, provide information about services available from different
agencies, and empower clients to choose and combine services to
effectively meet their specific needs.
Operational Objectives
Over time, the Pathways initiative has evolved to reflect seven
major goals:
 Increase Client Access to services
 Improve Program Services and Impacts
 Protect Privacy and Personal Rights
 Increase Efficiency and Cost Effectiveness
 Support Planning and Coordination of Services
 Sustain Public Support and Agency Buy-In
 Utilize Replicable Processes
These seven goals summarize a variety of more specific
purposes (Exhibit 2.1). A more detailed summary of goals and
objectives is provided in Appendix 2.
The Oregon
Pathways
System will
streamline
application and
eligibility
screening
processes, and
empower clients
to choose and
combine services
to effectively
meet their
specific needs.

21. Oregon Pathways Page 9
Pacific Management and Research Associates December 14, 2015
[1] Increase Client Access to Services
[a] Provide Universal Access to Variety of Services and Agencies
[b] Empower Clients with Self-Directed Access and Choice
[c] Support Client Choice of Services
[d] Simplify Intake and Needs Assessment
[e] Streamline Eligibility Screening and Verification
[2] Improve Program Services and Impacts
[a] Use Processes that Foster Client Self-Reliance
[b] Eliminate Unneeded “Paperwork” and Reduce Administrative Activities
[c] Integrate Services from Multiple Agencies to Holistically Service Client
Needs
[d] Increase Staff Time for Direct Client Service and Interaction
[e] Improve Staff Morale and Performance
[f] Emphasize Results and Outcomes
[3] Protect Privacy and Personal Rights
[a] Allow Clients to Review, Correct and Update Eligibility Data
[b] Provide Full Disclosure of Client Rights and Responsibilities
[c] Ensure Security Against Inappropriate Use of Client Data
[d] Allow Client Options for Deleting Unneeded Self-Reported Eligibility Data
[e] Allow Clients to Access Services without the Use of Pathways
[4] Increase Efficiency and Cost-Effectiveness
[a] Decrease Unnecessary Data Collection
[b] Streamline the Collection and Updating of Client Data
[c] Eliminate Duplicate Eligibility Determination and Verification
[d] Improve Client Placement and Targeting of Services
[5] Support Planning and Coordination of Services
[a] Remove Barriers to Cooperation Among Programs and Agencies
[b] Foster Cross-Agency Forums and Discussion
[c] Support Functional Cross-Agency Referral and Case Management
[d] Link to Other Related Initiatives
[e] Document and Assess Service Outcomes
[f] Share and Update Data Among Multiple Agencies and MIS
[g] Improve Accessibility and Quality of Data for Planning
[6] Sustain Public Support and Agency Buy-In
[a] Demonstrate Potential for Major System Change
[b] Involve All Stakeholders in Development
[c] Make System Easy-to-Understand and Use
[d] Document Service Outcomes (Link to Oregon Benchmarks)
[e] Maintain the Integrity of Existing Programs and Services
[7] Utilize Replicable Processes
[a] Use Transferable Technologies and Processes
[b] Ensure Usability in Varied Technological and Organizational Settings
[c] Maintain Acceptable Startup and Maintenance Costs
Exhibit 2.1
OPERATIONAL
OBJECTIVES FOR
OREGON PATHWAYS
This exhibit summarizes
goals for the Pathways
System that have been
developed through a
multi-year planning
process.

22. 10 Business Model and System Overview
Pacific Management and Research Associates December 14, 2015
3. Overview of Proposed System
The Oregon Pathways system will use information technology to
increase access to services and streamline intake processes. The
system will provide clients with multi-site universal access,
simultaneous eligibility screening for multiple programs,
cross-agency information and choice concerning available
services, and electronic application and referral to client-selected
programs. Foremost, Pathways will simultaneously determine
client eligibility for multiple programs and provide clients with
information and choices concerning the services they are eligible to
receive. This system will maximize return on resources by placing
clients within services that have the best chance of producing
positive outcomes, producing cost savings that allow the
realignment of staff responsibilities to client service, and establish a
technical foundation for cross-agency case management.
Initially, Pathways will provide universal access to the varied
social services provided by the following federal, state and local
public agencies:
 Adult and Family Services
 Community Corrections
 Community Development
 Employment Department (Employment Service)
 Employment, Training and Business Services (JTPA)
 Housing Authority
 Mental Health
 North Clackamas School District
 Public Health
 Social Security Administration
 Social Services
These agencies are also listed in Appendix 5. Clients can
obtain service information and determine their eligibility for services
at the site of any Participating Agency (Exhibit 2.2).
Pathways will
maximize return
on resources by
placing clients
with services that
have the best
chance of
pro-ducing
positive
outcomes.

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Pacific Management and Research Associates December 14, 2015
Clients seek service from any Participating Agencies.
All Participating Agencies provide entrance points that give clients
access to a comprehensive array of services:
 Community Corrections  Public Health  Employment
Department
 School District  Employment Training (JTPA,
Etc.)
 Social Security
 Housing Authority  Social Services  Mental Health
Agency staff meet with clients to discuss needs, use the Pathways
computer system to identify potential services, and determine client
willingness to use existing data to assess their eligibility for services.
Agency staff use the Pathways
system to find services to meet
the specific needs and eligibility
status of clients:
 Retrieve, verify, review and update
client data needed for eligibility
screening
 Simultaneously determine client
eligibility for multiple programs
 Assist clients to select services that
meet their individual needs
 Electronically transfer applications to
selected programs
 Provide client with referral information
 Reduce waiting period for services
The Client has the option of
obtaining a list of programs and
services, and applying through
the existing paper based
application process at each
agency.
 Client is given general information
about prospective programs and
services
 Client applies for services at each
agency through the traditional
paper application process
 Applications are processed
Applications are processed, eligibility determined
and services delivered to clients.
Exhibit 2.2
HOW PATHWAYS
DELIVERS SERVICES
Pathways simplifies and
streamlines client access
to services by providing an
overview of available
programs, electronically
screening for eligibility,
automating initial
application creation,
expediting referrals and
reducing the waiting time
for services.

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Pacific Management and Research Associates December 14, 2015
During the initial phase of operation, agency staff work with
clients to determine their needs and the types of services they are
seeking.
1
Clients and staff will work together to use a user-friendly
query system to identify and describe potential services. This
same system can also determine client eligibility for all services
provided by every Participating Agency, or for services specified to
be of particular interest to clients.
2
To determine eligibility for services, clients must give
permission to use eligibility data that currently exists within Best
Source agency databases (e.g. age, ID numbers, educational
background, employment history, date of birth, property ownership,
disabilities, income).
3
This permission is given when clients read
and sign a statement that allows the Oregon Pathways system to
access existing client data that is pertinent to eligibility
determination, and authorizes Participating Agencies to store and
exchange data on the clients’ behalf. This statement also specifies
limits on use of this data and client rights concerning privacy and
review.
Clients not wishing to give permission to access data from their
records may directly apply for services at agency sites.
If clients give permission to access eligibility-related data,
Pathways immediately accesses pre-existing data, works with
clients to enter or update missing or outdated data,
4
then uses a
computerized system to simultaneously determine client eligibility
for a variety of services provided by multiple agencies. All these
tasks are efficiently completed during the client’s first visit.
In cases where clients are not eligible for a specific service,
Pathways will provide an “eligibility audit” specifying the reasons for
ineligibility. If ineligibility is based on incorrect data, options will be
provided to make adjustments and reassess eligibility.
5
If clients are ineligible for desired services or decide not to use
any services, they have the right to delete all new information
entered during the eligibility screening process.
In cases where clients are eligible, they are given a choice of
the services they wish to use. This is done by giving clients a
printout with information about the services for which they are
1
Ultimately, the Pathways system will provide a kiosk option that allows clients to directly access information about services,
determine their own eligibility for programs, and initiate electronic applications and self-referrals.
2
Clients can choose one of two approaches for finding services. In the first approach, agency staff work with clients to review
potential programs and select services that best meet their needs, then Pathways efficiently determines whether clients appear
eligible for the selected services. In the second approach, agency staff use the Pathways system to determine all services for
which clients appear eligible, then Pathways provides information so that clients can select the services that best meet their
needs.
3
Best source data refers to sources of data that have been identified as having verified pieces of client eligibility data.
4
Data that is newly entered, updated or changed due to a challenge from clients will be electronically flagged for verification.
Verification will include date of verification, type of documentation, and agency/staff verifying data.
5
The specifics of the “eligibility audit” and remote eligibility data updating process will be designed and refined in response to
field testing. It is envisioned that Pathways will provide a number of alternative processes which allow clients and staff to
balance the goal of efficiency with the goal providing clients with a choice of available services.
If clients give
permission to
access
eligibility-related
data, Pathways
immediately
accesses
pre-existing data,
then
simultaneously
determines client
eligibility for a
variety of services
provided by
multiple agencies.

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Pacific Management and Research Associates December 14, 2015
qualified, and referral instructions for services provided by other
agencies. Agency staff will also counsel clients as needed.
At this point, clients will specify the services they wish to
access. Clients will then contact selected service providers for
final processing and eligibility verification. This process will be
streamlined by the electronic transfer of referral notices to
designated agencies along with pertinent pre-existing and newly
entered data. This transferred data will be incorporated into either
a computer screen or paper printout of service applications that can
be completed by applicants. These applications will be forwarded
by telecommunications to specified Participating Agencies. At
some point, “digitized signatures” may be used to further expedite
the application process. Currently, the design calls for the storage
of data indicating at what agency the release can be found. After
this universal intake, clients may visit, phone or correspond with
agencies providing desired services.
Newly entered data, eligibility determinations, and referrals will
be transferred to the agencies providing services selected by
clients. Agencies receiving this data will use it in accord with the
their existing guidelines concerning applications, eligibility
verification and client rights.
It is expected that this process will greatly reduce the cost, effort
and time required to apply for services, determine and verify
eligibility, and initiate service delivery.
4. Linking System Goals and Functions
Design and selection of technical components for Pathways
requires an explicit statement of the practical functions that must be
performed if the system is to meet specified goals.
Exhibit 2.3 provides a detailed linkage of functions to Pathways
goals. This list was developed by linking specific functions to each
goal and sub-goal. Specific functions - many of which are linked to
more than one goal or sub-goal - were then classified into five
global functions:
 User Interface and Security. These functions entail
screens and other devices which allow users to interact with
the system. An important part of the interface are a variety
of security functions.
 Data Entry, Storage and Retrieval. These functions deal
with the entry, storage and retrieval of data to and from a
variety of storage devices.
 Data Processing. These functions deal with a wide array
of procedures that transform data (e.g. listing, sorting,
filtering, translating, and calculating).
Operational
design and
selection of
tech-nical
components for
Pathways
requires an
explicit statement
of the practical
functions that
must be
per-formed if the
system is to meet
specified goals.

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Pacific Management and Research Associates December 14, 2015
 Data Transfer. These functions employ a variety of
approaches to move data from one location to another.
 Policies and Procedures.
This listing of specific and global functions has been reviewed
and edited to remove duplicate listings of functions (Exhibit 2.4).