April 2022

As Yvonne and Erika and I launch Sage Squirrel Consulting 2.0 and plan for our future, we pause for a minute to recognize and appreciate how we got here.  In 2017, Debbie Pierson had a vision.  I thought it was bananas, but I also trusted her because she was the most competent person I have ever had the good fortune to work with. Debbie – probably to no one’s surprise – turned out to be a natural-born consultant, and her vision became a reality. Sage Squirrel Consulting became a legitimate consulting firm

When Debbie passed away this summer, I thought that Sage Squirrel Consulting was going to pass away too.  Much to my amazement and good fortune, that is not the case.  This month, we renew Debbie’s vision for a consulting firm dedicated to the idea that good policy, combined with accurate, consistent and effective operations in a person-centered system, are the keys to states being able to help vulnerable people get the resources and supports that they need, where and when and how they need them. 

I could go on at length here about how special Debbie was, but we don’t have the space for that. If you ever worked with her, you know what I’m talking about.  If you never worked with her, I’m sorry that you missed out.  Her spirit was definitely at work bringing the three of us together last fall and I hope we continue to channel that spirit as we take the firm into the future. 

I am more grateful to Debbie than I can ever express for how she supported and guided me to learn the ropes – first in the Division of Aging and later as a consultant. Her faith buoyed me then and continues to help me believe in myself. The best way for me to express that gratitude is to carry on the work that she loved, so with that, we begin (again). 

In memoriam – Debbie Sue Pierson

I stumbled across an article from a 1950 issue of The American Political Science Review titled “Administrative Stability and Change”. I laughed out loud as I read it and then I sent it to Debbie right away because I was astounded at how relevant and applicable the article still was! One of my favorite passages in the article says: “…institutions tend to become sluggish, to lose their sensitivity, flexibility and capacity for ready adjustment.” I couldn’t have said it any better than that even though it’s now 2021 – 71 years after the article was published!

One of the themes Debbie and I frequently return to is about how many organizations, particularly governmental organizations, or those that are closely dependent on government organizations, seem to prize stability and compliance over outcomes. But in today’s world, achieving desired outcomes requires a more nimble and responsive approach – one that government entities struggle to develop. The article outlined some of the reasons for why this may be – and why it’s been that way for a long time.  

The article discusses the dynamic that occurs between “permanent” career staff and the appointed leaders who come and go with political administration changes. It reminded me of a person I worked with who once described state career staff as what she called “wee-bees” as in “we be here when you came, we be here when you go”. That may be apt for a certain subset of career government staff but the majority are well-meaning public servants who truly believe that they are doing work that is in the best interest of the public they are serving; but….

That cultural inertia that prizes stability above all prevents a lot of career staff from being able to see beyond compliance – and that may even prevent them from seeing the larger picture or buying into a transformative agenda because that threatens their stability and continuity. While this is understandable, that inertia has the potential to pull appointed officials – even the ones who come in with big agendas – into that mindset. Remember – culture eats strategy for lunch, and this is a culture with its own gravitational force.  

I have observed a number of state administration transitions by now and there are some patterns. Sometimes the incoming officials get sucked into that gravitational force and fall victim to the low risk, compliance-focused organizational culture. Some come in with a mindset that the career employees are a force to be vanquished and overcome in their quest to achieve their policy objectives. The best ones come in and are able to gain buy-in to new goals, to motivate career folks in new directions, and to sort out the ones who are not able or not willing to get on board with a new direction. (Again, nothing really changes as the 1950 article basically outlines the same three scenarios!)

A successful organization in today’s world, even a government organization, needs to be nimble and responsive to change, to even be an agent of a change at times. Successful managers must be able to recognize and address these cultural issues. We have said, frequently and publicly, that when you are trying to accomplish real transformation in your organization, the single most important thing you need are some key people who have strong people management skills – not just vague “leadership” attributes, but actual concrete skills in developing people, delegating, coaching, and keeping people accountable. Without those skills, “leadership” can just be wishful thinking. Unfortunately, managers don’t always get the training and support they need to develop these critical skills, particularly in government organizations or those dependent on public funds.

As our author said in 1950, “…an essential value in government is continuity”. I don’t necessarily think that means that the same problems that were discussed in 1950 are supposed to be completely relevant in 2021 but it’s true what they say – the more things change, the more they stay the same!  

This isn’t destiny though. While these cultural issues are a big reason for why publicly funded LTSS programs are so fractured, there are organizational changes that can be made to help agencies be nimbler. They can become more adept at responding to change and supporting the culture change that is part of developing more person-centered systems of administration and service delivery. In coming blog entries, Debbie and I will share strategies for helping your government (or government-adjacent) organization be better equipped to tackle a transformative agenda or to at least be able to respond in a more agile fashion when opportunities present themselves. We don’t have another 70 years to meet the human service needs of the next couple of decades.  

Excerpts from:  Esman, Milton J. “Administrative Stability and Change.” The American Political Science Review, vol. 44, no. 4, 1950, pp. 942–950. JSTOR, www.jstor.org/stable/1951295. Accessed 8 Jan. 2021.

We have come to the last (but not least!) element of ACE – Efficiency! Thanks for staying with us! Let’s start where we have started before – with the dictionary. The Oxford Dictionary defines efficiency as: “the quality of doing something well with no waste of time or money.” I particularly like that there is no comma in this – it underscores that efficiency is about doing things well AND with no waste of time or money.  

If we stick with the restaurant example we have been using:  Accuracy is making the food or assembling the order correctly – according to the recipe and/or according to how people ordered it. Consistency means doing that for every item and for every customer. But – if you wait an hour for that order, or if it takes fifteen people to make the sandwich, or if they waste a bunch of food in order to get it right, the business is not going to remain viable for very long. Either customers will stay away in droves, or you will lose so much money that you can’t survive. You have to be efficient in how you use your resources in order to be effective.   

Resources tend to be scarce in LTSS – especially Medicaid-funded LTSS. We have always operated from the philosophy that this system is built on taxpayer dollars and people who administer those dollars have a very high level of responsibility to ensure that those dollars are maximized for the public good. This means that you need to use your resources as efficiently as possible. When you are contemplating the need for additional dollars and how to request those dollars, you need to ensure that you are as lean as possible in your administrative processes.  

Conducting surveys, reviewing and approving Medicaid applications, conducting assessments are examples of common LTSS-related transactions (although not inclusive!). The same principles apply – you must get it consistently right while using your resources most effectively. By resources we primarily mean time and money, but people and process are the vehicles that utilize that time and money. Your efforts at improving efficiency will center on people and process. 

A first step in assessing efficiency is figuring out how you currently utilize resources. That might mean a hard look at budgets. It could mean some time studies or other productivity measures. Done well it most certainly means a thorough look at your human resources – do you have the right people, and do you have them in the right roles? Your people are critically important; a lot of efforts around efficiency are about how you manage your human resources. 

As with accuracy and consistency, technology is a significant tool. Automating data collection or data entry, using electronic forms, or data feeds can save you from the need to manually enter data – and prevent some of the human errors that are inevitable when you are handling data manually. Done well, this will naturally lead to gains in efficiency.  

An efficient process is one that adds value with each step. It’s important to figure out why you do each piece: Why do this in triplicate? Why do we enter this information? Why is this filed in two places, etc. Know that the first answer to “why” is often “because that’s how we have always done it”. You will need to move beyond and keep asking “why” until you get to the root reason – and then decide if it is a good reason.  The other day I heard someone say we had to decide if the lemonade was worth the squeeze (I love that!) The same goes here – is what you gain from that step or process necessary enough to keep doing it or to keep doing it that way?

Increasing efficiency may mean you need to make some investments. This may be an investment of time – to analyze the problem, or to develop new tools. It may be an investment of financial resources like purchasing new technology. Training your team in new ways of doing things is an investment of both time and money. Don’t be penny-wise but pound-foolish. If you have to make a request for additional funds, you must make the business case about the long term savings as well as what those efficiency gains will enable you to do.

Accuracy is getting things right. Consistency is getting things right all the time.  While accuracy and consistency are both critically important, you can’t sacrifice efficiency in order to achieve them. You need all three to in order to “ACE” your business operations and maximize your performance, your outcomes and your value. 

Accuracy is the first principle of ACE, but accuracy alone isn’t enough if it is not applied throughout your organization. Consistency is the second principle of ACE and it is just as important as accuracy is in establishing your credibility. The Oxford Dictionary defines “consistent” as:  always behaving in the same way, or having the same opinions, standards, etc.

Accuracy means you are getting it right – consistency means you are getting it right all the time. Consistency may mean that you always put two pickles on the sandwich, but it also means that different people come to the same correct decision about matters of interpretation. You may recognize the latter as “inter-rater reliability”. Inter-rater reliability is the extent to which multiple people come to similar conclusions and establishes the consistency of any given system of assessment or evaluation.

Consistency can also refer to process. Regardless of individual decision or outcome, the process involved in making that decision is consistent. That consistency of process is also part of how you reach “inter-rater reliability”. 

Achieving operational consistency takes a combination of coaching and tools, including the use of technology. As we discussed in our last post, tools and technology are good ways to facilitate accuracy by limiting the scope of human error. The use of tools and technology also helps establish consistency as long as they are used by all of those who perform a task. 

Here’s an example:  The nursing facility survey process is one that has been notorious for inconsistency and subjective assessment. Providers have complained for years about the fact that survey results can vary widely based on the surveyor. Over the course of 2018 and 2019, CMS rolled out an updated survey process. The new process included updated tools and automated certain elements in an effort to increase the overall level of consistency in the process. While it is still too early to ascertain definitively that this process is more consistent, we have heard favorable information from state survey agencies who believe that the process is leading them toward more consistent determinations. 

Another example is nursing facility level of care. Using the right tools can reduce reliance on subjective decision-making or eliminate the ability of individuals to “override” determinations by substituting their own judgment.  

Tools and technology can be of limited value where judgment calls ultimately have to be made especially where they can appear to be very subjective. Employee performance management is an area where different supervisors can see the exact same behavior or results and come to completely different conclusions. Tools like behavioral anchors can help but not eliminate this challenge.

In these situations, organizations can work to “calibrate” assessments. This can be achieved a couple of different ways. One well-trained person’s assessments can stand as the standard against which other assessments are evaluated and people are trained until their determinations are similar. Another way to do this is to hold “calibration” meetings in which assessors gather to discuss their evaluations and identify variables that need to be hashed out among the group in order to come to similar conclusions with similar inputs.  

Achieving consistency takes ongoing effort. It’s not something that you can just set and forget. Managers need to continuously monitor results by setting up reports and reviewing these regularly. Technology can assist here but this can also be done with Excel spreadsheets. 

Measure and track error rates. It’s all the better if these can be tracked at the agency, team and individual levels. It will aid you in being able to identify outliers and to troubleshoot problems. When mistakes happen, figure out why they happen at the root cause level and correct those root causes.  

When consistency and accuracy come together perfectly, you could be 100% accurate. While that may be a stretch goal, you can set incremental goals along the way to 100%. The consequences of working in human services is that errors have a direct impact on people’s lives – some profoundly so. Standards should be high.

As you set ambitious goals for your team, make sure you tie these goals to your organization’s mission and/or your strategic plan. Explain why it is important. Create a clear line of sight for each individual from their individual goals and responsibilities to those of the organization as a whole. Everyone should understand how they contribute to mission accomplishment. 

Your processes build reliability and gain in confidence with internal and external stakeholders as accuracy and consistency improve. But you are not an ACE yet. Efficiency is up next. 

When Debbie and I were in the state agency, we wanted to reduce turnaround times for some of our common transactions. We started to measure transaction processing times and put up boards to track those times and formulated plans to bring those turnaround times down. That seems like a good plan if those times are important (and they were because people’s lives or providers’ livelihoods were at stake) – but – how important was it to be fast, if we weren’t doing it accurately? If people got the wrong answer, or if a process had to be re-done, had we gained anything? We realized that it didn’t matter if it was fast if we got it wrong –we couldn’t sacrifice accuracy for speed. While all of the elements of ACE are important, the others don’t matter without accuracy. Accuracy is the first element of “ACE”.

According to the Oxford dictionary, “Accuracy” is defined as:  “the quality or state of being correct or precise”. The sub-definition reads “the degree to which the result of a measurement, calculation or specification conforms to the correct value or a standard”. 

If your agency or organization is performing any type of repetitive task you need to have some type of standard against which you are measuring. We have written before about our previous experience managing restaurants – accuracy means that the customer’s order is made correctly:  according to the standard of how the customer ordered it and according to the proper recipe. Accuracy in Medicaid eligibility means that the determination of eligibility was made correctly according to the policy standards. If you are performing survey oversight visits, the visit documentation should clearly capture what is being observed and determinations of compliance are made against the regulatory standard.  

The word “accuracy” conjures up the notion that one is either accurate or one is wrong.  That accuracy is either black or it’s white. Some things are straightforward – the sandwich gets two pickles, it’s got two pickles, eligibility threshold is $X, individual has less than $X dollars, you provided 10 units of service, you submitted a claim for 10 units of service. Other things have some gray area – does the setting promote community integration, does the individual need X hours a week of personal care, does the individual meet nursing facility level of care, is the care plan increase warranted, etc. Those shades of gray may be found in how regulations are interpreted, how documentation is interpreted, how decisions are made using the information that is at hand, among other things. These are all common in the LTSS world.  

What does it take to instill an accuracy mindset in your team? You and your team have to know what accurate looks like and how to achieve it. You must consider all the elements of an accurate decision or action. What rules are there; what policies or procedures must be followed; are there caps, limits, minimums, etc. that must be applied?

Creating process flows, decision trees, job aides, etc. can help to minimize the gray areas, improving accuracy. Automation in processes reliant on data entry can improve accuracy by eliminating human error, i.e. “typos”. 

Technology systems that use strong business rules or even algorithms can also help improve accuracy. Things as simple as checking digits in a phone number you enter, validating zip codes, checking for blank fields that are required in certain steps of the process, even spell checking notes and other documentation, allow you to use technology in pursuit of accuracy. More sophisticated systems might flag outliers, like high cost care plans, unusual variations in recorded assets or income, extreme changes in assessment scores, etc. for additional review to catch other errors.

Achieving accuracy is critical to developing faith and confidence among your stakeholders – whether those are customers to your restaurant, people applying for Medicaid for long term care needs, or providers who rely on the survey process as a key measure of the quality of care that they provide.  But being accurate once doesn’t build that confidence, it’s getting it right every time. And that is Consistency. More on that next time.

Despite the fact that we never even met each other prior to 2014, Debbie and I discovered when we began working together that we have very similar business philosophies. It took us a while to clearly articulate them but we both knew pretty quickly when we met that we were on the same wavelength and that helped form the basis for a unique and special partnership ever since. 

The two key ingredients in Sage Squirrel’s “special sauce” are that we both believe firmly that compliance is the foundation for excellence, not actual excellence; and that it doesn’t matter how good your policies are if you can’t execute them effectively. This has morphed over time into our key principles:

  1. The need to go beyond compliance in all things, and
  2. The need to ensure that business operations are designed to ensure accuracy, consistency, and efficiency – what we call “ACE”. 

We’ve talked in this blog quite a bit about going beyond compliance so I thought I would do a little deeper dive into ACE. We have been talking a lot lately about quality improvement and performance management and ACE is foundational to doing both. And we assume that everyone wants their business operations to produce accurate and consistent results as efficiently as possible – that’s ACE.

When we talk about business operations, we are talking about the systemic combination of organizational structure, technology, and business process design that allows your agency or company to actually accomplish needed work. That work may be production of something, it may be the provision of services, assessments, or the processing of transactions such as enrollments or approvals of actions. Of course, this list is not exhaustive – it is meant to be illustrative of the fact that you may not always think that you have business operations but the reality is that all organizations actually DO something.  

I once carpooled with a gentleman who ran a small state agency. He was very resistant to the idea of performance or quality in his agency because, in his words, “Our job is to monitor (their) quality and compliance – we don’t perform anything”. Actually, his agency administered processes that were pretty similar in nature to those associated with nursing facility surveys. That type of monitoring activity is business operations just like producing widgets or processing applications is business operations. 

There is no one magic bullet that makes ACE happen. You can’t do it with technology alone; you may have a good form or other tool, but an overly bureaucratic process to get it completed; you may have high performing employees but an organizational structure that fosters impermeable silos rather than centers of excellence.  

We talked about this in one of our In a Nutshell briefs:  ACE is about more than just getting the task done. It is all about making sure it is the right task, done the right way, by the right person. That’s what can allow you to make the most of your resource and go beyond mere compliance in the pursuit of quality – that’s operational excellence. Some of the elements to achieving ACE include:

  • Get the right people in the right roles and equip them well with strong onboarding, training, and resources
  • Create accountability with well-defined expectations
  • Ensure business processes add value and are efficient and effective
  • Use technology as a tool to automate process elements wherever possible.

Over the next few weeks, we will come back and fill you in more on our thoughts on each element of ACE – accuracy, consistency, and efficiency. We would love to help you ACE your operations!  

There has been a flurry of activity with states filing Appendix K and 1135 waivers in an effort to ensure service continuity despite challenges associated with the COVID-19 pandemic. These waivers are all designed to create flexibilities for providers and state agencies. Examples include expanded use of remote technologies, allowing use of alternative settings, suspension of some screening (PASRR) and prior approval processes, streamlined certification for new providers and to allow existing providers to add alternative services, and waiving face to face assessments for initial or annual eligibility, and many others. 

All of these changes are rooted in reducing or eliminating regulatory requirements that are perceived to be obstacles or barriers to service access and/or provision. Many of these  emergency flexibilities are things that providers and/or other stakeholders have been complaining about for some time. In some ways, the long term care system has been facing a slow motion crisis for some time now. The pandemic is bringing demographic changes and workforce capacity issues to light in an urgent and dramatic fashion.

The American LTSS service delivery system is not prepared to meet the challenges associated with the rapidly growing numbers of people who will need some degree of long term services or supports, and the strains that will place on Medicaid as the largest payer source for LTSS. While states and their federal partners have been working to make changes that will aid in meeting those needs, those efforts have been incremental, nibbling around the edges of needed change and possibly constrained by cultures organized around compliance and risk mitigation. They are not keeping pace with the demographic changes and the workforce challenges that abound impacting LTSS system capacity and quality. 

Regulatory structures are major drivers of LTSS service delivery systems all over the country.  Disrupting these structures could be a way to introduce needed change to LTSS and what could be more disruptive than a global pandemic? Disruption is often a necessary element in transformative change. This disruption, while unplanned and definitely not welcome, may provide an opportunity that should not be wasted. While we would never want a pandemic in order to spark transformative change in LTSS service delivery and regulatory structure, there is an opportunity here for state and federal regulators and payers to give careful consideration to what they need and why they need it before just reinstating all of the previous requirements when things return to “normal”. 

While the pandemic is certainly not over (sadly), the flurry of emergency activity may be slowing down. In a perfect world, close consideration would have been given to the longer term consequences of the emergency measures (see our last blog entry), but the last few weeks has seen rapidly changing guidance that have varied widely across the country, so situations have been fluid and suggest that long term implications have been a secondary consideration. Now may be the time to look forward to what will happen on the other side of the pandemic.  

Telehealth has been a topic of strong interest for years now in terms of building system capacity and improving quality of care, but payment systems have been slow in places to take that up. Workforce challenges should drive us all to consider the role that informal caregivers play in supporting people and how systems can support and maximize their ability to do this. People are better off in systems of consistent care and support so why shouldn’t providers like adult day centers have the flexibility to provide blended support models? Improving the speed and ease of access to home and community based services in order to prevent costly or unnecessary nursing facility admissions has been a challenge for states attempting to “rebalance” their Medicaid spending.

I don’t know anyone who thinks that the world is ever going to be “normal” again – there will be a new normal as we adjust to the long term presence of the COVID-19 virus and its impacts on our health and livelihoods. The pandemic has been and will continue to be a significant disruption in every area of life including LTSS. It would be a shame to simply go back to “normal” without making the most of this disruption. State and federal agencies, providers and advocates can all consider what changes are actually beneficial to systems and working to make adjustments to capture that benefit for the long haul.  If there are regulations that are truly barriers to access, or prevent the use and support of informal caregivers, or make it difficult to use telehealth and other remote monitoring tools, then isn’t it time to look at them even once we are past this pandemic? Let’s not waste this crisis. There are lessons to be learned and disruption enough to fuel real change. 

Sharing a new In a Nutshell that goes along with yesterday’s blog entry on Responding and Not Reacting.

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

For the last two weeks I have tried to do my normal grocery shopping and have been forcefully reminded that things are most definitely not normal right now. Saturday, I went to five stores in two towns and was unable to buy what I needed to cook for the week. Sunday morning I went back out again – and ended up in a queue before the store opened. That was a first! People have clearly been taking the COVID-19 pandemic seriously, but some of the reaction is driven by mixed or mis-information, or the rapid nature in which information is evolving. 

We also see that seriousness in our interactions with providers and state agency staff in recent weeks as well. While there is always urgency in providing care and services to vulnerable populations, that urgency is ramped up to an unprecedented levels. We have been reading about Appendix K and 1135 waivers that states are submitting and we are both observing and participating in communications that are taking place between states and providers.

The difference between “responding” and “reacting” is subtle but clear. When one reacts, one is typically acting with little thought – it’s more like acting out of reflex, like a knee-jerk. A response takes more thought and consideration. Reactions happen quickly and usually don’t take longer term effects into consideration. Responses, because they are more thoughtful, can address the longer term and bigger picture issues.  

There’s a lot of reacting going on right now. The grocery stores are one of the clearest examples of that. People reacted and cleaned out the stores – the supply chain simply hasn’t had the capacity to ramp up in a meaningful way and stores are short of many of the basics of everyday living.  

Given how vulnerable older people and people with chronic health problems are to the novel coronavirus, it’s important that publicly funded services continue to ensure their health and safety. It’s incumbent upon state agencies and providers of services to older adults and people with disabilities to respond appropriately to this crisis – not just react. 

Some questions to help make sure you are responding and not reacting:

  • Can you state clearly what the problem is that you are trying to solve?
  • How will taking these steps help solve that problem?
  • Will these steps create other problems?
  • Do I know what the potential unintended consequences are?
  • Are there other ways to solve this problem?

Involving stakeholders in the identification of problems and solutions can mean better decisions. Communication and education are key to successful implementation. This is just like the actions that agencies take in approaching change management. The urgency around the pandemic doesn’t mean that you shouldn’t go through these steps. It does mean that they have to happen faster. This crisis is unlike anything we’ve ever experienced. But there is a likelihood that this will be the new normal for a more protracted period of time than it would be for a hurricane, or a flood, or a tornado, or a fire. Operations could be impacted for months. State and provider agencies will live with the consequences of what they do now for months. Responding rather than reacting reduces the likelihood that you will create more problems at the end of that time. 

I have an hour-plus drive each way to the office and I find that podcasts are both a great way to pass the time while educating and/or entertaining myself along the way. There’s not much rhyme or reason to what I listen to, topic-wise. It may be history or popular culture or true crime – or current events. One that I listened to recently caught my attention because it touched on things that Debbie and I have been talking about and working on for a number of years now and framed them in a slightly different way for me.  

The subject of the podcast was the role of “administrative burden” in policy making and policy outcomes. The premise was that policymakers make decisions about desired outcomes and shape administrative requirements to drive those outcomes. They provided Social Security as an example of how government eased administrative burdens because they wanted people to access and use the benefits; examples of how governments create administrative burdens as a deterrence to accessing or using benefits were Medicaid and SNAP benefits, and requirements around voting.

We have also seen and been frustrated by processes that are unnecessarily complicated, that don’t take advantage of available technology, or that completely shift the burden to individuals who just have to keep trying until they get it right. This is particularly troublesome when you are talking about a frail older person who needs supports to stay at home and avoid going to a nursing facility. These are highly unlikely to be fraudulent applications. The cost of those delays is the increased likelihood of nursing facility placement and the administrative costs with processing an application three times for an individual who has been eligible all along but couldn’t get the paperwork right. That’s not efficient or humane.

As the podcast went on, I began to consider that it might not be quite so black and white. Some of these administrative burdens may be seen as defensible. The risk of fraud is one of the reasons cited for the heavy administrative burdens associated with Medicaid that falls squarely on the applicant. However, there is little discussion about how expensive these administrative systems are to maintain and whether that expense is justified by the extent of risk that a non-eligible person may receive benefits, particularly in this day and age, where a lot of this information is already available in an automated format. 

While I have no doubt that there is some political context around some of these decisions, some of these practices are just rooted in the culture of government at all levels to minimize risk and ensure compliance. They tend to be self-sustaining once in place. Debbie and I can both think of multiple examples of individual employees who created administrative burden because they were concerned about the possibility of one bad actor slipping through the cracks, despite the fact that such instances are rare and the costs associated with the increased workload far exceeded the risk of the bad actor slipping through.  

I have every confidence that most people who administer programs targeted toward persons who are elderly and/or who have disabilities actually want people to access and use those benefits. Institutional placement is far more costly in most cases and quality of life may be superior when people can remain in their homes and communities. But bureaucrats are frequently products of the environments they grow up in and don’t always recognize that systems and processes are burdensome 

It’s true what they say: the first step to fixing a problem is recognizing that you have one. If people who are in the systems don’t understand the upstream and downstream impacts of what they are doing and the full measure of risks and costs, then they likely don’t recognize that there is a problem in need of fixing. They may even see adverse program outcomes and not recognize that they are contributing to that. For example – people going into nursing facilities because HCBS can’t be started quickly due to assorted administrative requirements.  It’s always easy to blame the OTHER requirements.  

We were both fast food managers once upon a time and understanding the customer experience was of paramount importance so we may have some heightened sensitivity. This was an area of focus for us while we were working in Indiana’s Division of Aging and they are continuing to work on related issues so we are hopeful that Indiana will work to streamline and simplify access to LTSS. Streamlining access to LTSS is one of the tenets of No Wrong Door systems so other states have been working on it as well. 

Fresh eyes are one of the best ways to spot these kinds of issues. People who haven’t been around the system for a long time are among the quickest to see things. Soliciting input from those fresh eyes can open your eyes to how your systems are experienced by users, both providers and consumers. That input may come from new hires, consumer advocates, or consultants – including the squirrelly ones! 

Administrative burdens aren’t limited to state and federal programs. Any organization can create administrative barriers or obstacles that impact people that work there or people that they serve. There are some ways that you can learn about those issues and address them. Invite those fresh eyes, be open to feedback from people who bring you concerns about complicated procedures and don’t let your processes get stale. Sometimes “we’ve always done it this way” is why things get more complicated than they need to be. Institute ongoing review and validation to ensure that your procedures are always accurate, consistent and efficient.