The Whole is Greater…

When I was my father’s caregiver, I frequently felt alone and confused. I didn’t always know the best way to support him, or how to navigate the murky waters of LTSS. I had heard of Area Agencies on Aging, but I thought that they were just for poor people who needed Meals on Wheels. I didn’t even know enough to ask the right questions – I tended to conflate home-based services with in-home palliative or hospice care. His doctors’ offices weren’t any help at all – they each wanted to pass me on to the other ones without answering any of my questions.

My dad may not have qualified for Medicaid, but we still could have used assistance with understanding the system, what our options were, and how to piece together a plan for supporting both him and me (that may not have led to his disastrous stay in assisted living described in previous post!). We needed information to make good informed choices for his long-term care needs. I didn’t know to even try turning to a AAA for that assistance. I’ve certainly learned a great deal since then!

Since that caregiving experience, I have come to be a real fan of the AAA network, or, to be more accurate, the potential of the AAA network. Since the creation of the aging network 50 years ago, AAAs have been the vanguard in identifying challenges that the aging population faces and in developing solutions to those challenges. They were addressing the social determinants of health before that term became so commonly used.

Their experience in person-centered options counseling and community-based case management equips them to be natural partners to health care systems seeking to improve outcomes associated with transitions of care, or caregiver support. Their potential for community partnerships and referral experience made them a natural fit as Aging and Disability Resource Centers (ADRCs) in many states. As such, it is also natural for them to have a prominent role in state No Wrong Door systems.  Many function as the entry point to Medicaid-funded LTSS, but it may be more important that, through person-centered options counseling, they have the potential to provide access to less costly, earlier interventions that may prevent or delay the need for Medicaid-funded services.

Some AAAs are already forming robust partnerships with healthcare partners that are proving fruitful for both parties.  Some AAAs are working to gain business acumen skills to develop their abilities to get those contracts.  These are successful individual organizations, but not necessarily successes for the network as a whole.  We were just at the n4a (National Association of Area Agencies on Aging) annual conference last Monday.  It was great to celebrate the individual success stories, but the continual use of the word “network” seemed to imply that all AAAs were performing similar activities, and almost obscured the fact that many AAAs are really struggling just to stay afloat.

Aristotle said, “the whole is greater than the sum of its parts.” I believe that is true of the potential of the AAA network in any state.  I think it was also Aristotle that said, “the worst form of inequality is to make unequal things equal.” In my observation, AAAs don’t’ act as a true network and some of this may be due to the fact that there is such variation among them in capacity, skill, and mindset.

At the n4a conference we also heard Lance Robertson, Administrator and Assistant Secretary for Aging, speak about the future of the network and the potential opportunities for building a stronger network.  He (very politely) challenged them to move forward and indicated that not all may be able to.  A couple of his tenets stuck out with me as particular parts of this challenge:   the need to acknowledge and address weaknesses; the need to fight against the scarcity mindset; and the need to encourage each other.  The scarcity mindset in particular, I think, leads to an organization making it someone else’s responsibility to “fix” their inabilities.  It goes hand in hand with an unwillingness to self-examine one’s organization and honestly identify and be willing to address areas where improvement is needed.

The ACL and the state units on aging are also critical components of this aging network and share some responsibility for facilitating, supporting and challenging AAAs to grow and change.  As a manager and an executive, I have always sought to raise the bar for my team or my organization.  Raising the bar in terms of expectations for performance, for real outcomes, can bring out the best in some.  There will be those than cannot rise to the challenge. States can be good managers trying to raise the bar for their AAA networks by:

  • Defining desired outcomes;
  • Setting clear expectations;
  • Measuring performance/outcomes; and
  • Creating systems of accountability with consequences.

The network’s strength depends on everyone’s performance improving – the strong ones pulling the weaker ones up.  Those that can’t reach the higher bar cannot be allowed to hold the rest of the network down.  Whether it is a managed care entity, a health care system, or a state building capacity in their LTSS system or creating a No Wrong Door system, they all need a AAA network that is strong, not just a few strong AAAs defining their own success.

States and payers can and should be investing in their AAA networks. The ACL has certainly provided tools and resources for the aging network to foster this – the business acumen development resources, the investment that has been made in No Wrong Door (including the current grant opportunity around RoI).  AAAs must begin to understand and accept that increased opportunities also come with the increased expectations and requirements and to find ways to work together in meeting those.

I want to believe that if I had known and made the call, I would have received the help I needed; but I am not sure that individuals and caregivers in similar situations can make that call and consistently get the help they need. I fear it depends too much on which AAA they called. That’s not a network.  That’s not a system where the whole is truly greater than the sum of its parts … but it could be. I believe in that potential and believe it’s worth working for.

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