We know we promised you a series on operational/organizational effectiveness, accuracy/consistency/efficiency (ACE), and going beyond compliance, but something happened this week that reminded us why doing these things is so important.  We will get back to our series with our next entry.

My brother’s wife is now somewhat frantically trying to arrange care for her Aunt K.  Aunt K lives in Indiana – my brother and sister-in-law just moved to Florida.  Aunt K has been in a rehabilitation facility, paying out of pocket because her Medicare Advantage plan said that she no longer qualified for therapy and the facility says they have to discharge her.  Aunt K has suffered some cognitive decline while in the facility and the rehab staff are referring her to assisted living, saying that Aunt K won’t be safe going home alone which is how she lived until her recent surgery.

My brother expressed to me “Our top priority is Aunt K’s safety. We want her to be 100% safe.”  I suggested that if she doesn’t want to be in a facility, perhaps they might want to listen to what she wanted and work to find a way to balance that with the safety considerations.  I was shocked when he said “that might be fine for now, but at what point, does what shewants just go out the window?”  Suddenly, Aunt K is no longer a grown woman, retired teacher, who just a few weeks ago was independent with a rich and active social life. So often in the midst of a crisis, the person ceases to be a person and becomes a problem or a situation that has to be handled. Now everybody just wants to “put” her somewhere where she will be safe, and they want it to happen quickly.

Aunt K has some money in the bank and income from a pension.  She owns her own home free and clear.  She’s not in immediate danger of requiring Medicaid assistance, so in theory at least, the state has no interest in Aunt K’s outcome. But is that really true?  Why should state systems care about people like Aunt K? Let’s break this down (in a somewhat oversimplified fashion):

  • If my sister-in-law really wanted to ensure only that Aunt K was “100% safe” one option would be to admit her to a nursing facility as a private pay resident.While the appeal has been pending, she’s been paying $372/day.  Assuming no rate changes, $100,000 would buy her about 268 days, about nine months in the nursing facility.
  • One can’t guarantee 100% safety in an assisted living community, but there is staff presence 24/7. If we assume the Genworth average cost of assisted living (~$3900/month), $100,000 would buy about 25 months of care.
  • If Aunt K would prefer to stay at home and can do so in an acceptably safe fashion with a few hours a day of personal assistance and support from her active network of friends, that care would cost around $100/day and $100,000 dollars will last about a thousand days, or 3 years.

Medicaid is the largest payer of LTSS in the country, and LTSS is becoming a larger and larger portion of those expenditures as lifespans increase. It is in the state’s best interest to help people access good information about what’s available to them and how they can use their personal resources in the way that best balances what is important to them with what is important for them.  A person in this situation with $100,000 available to pay for care potentially delays running out of funds and becoming Medicaid eligible for up to a year.  Even better, that person and their circle of support retains the ability to manage their own affairs and make choices that are congruent with their goals and preferences.

Long term care is not easy for people to navigate and way too often, they are trying to do so while they are in a crisis.  Most people say that they would prefer to remain in their own home, but don’t always know what they need to do to identify and set up services they might need. When there is no access to unbiased, person-centered options counseling, the pathway to LTSS becomes rather narrow. For decades, that pathway led straight to nursing facilities. Now the path is shifting to assisted living. That sector is seeing burgeoning demand for their services, but it is unclear if that is reflective of overall demand or just that AL is the only pathway people think they have.  Assisted living operators work hard to make their services a very visible option to individuals and their families. If people had equal access to information about the range of service options available to them, they might make different choices,

No Wrong Door systems are intended to promote access to unbiased information and resources that people need to make their own best decisions regarding LTSS.  No Wrong Door systems require investment on the part of the state and federal governments, for technology, marketing and outreach, training, and funding high quality options counseling for people, regardless of payer.  To date, it’s been very difficult to quantify the benefits of this investment because it’s hard to measure.  People like Aunt K do not show up in a lot of the data decision makers use until they are eligible for Medicaid, although the consequences for Medicaid are great, if there is no No Wrong Door system of access to help people like Aunt K.

ACL recently funded ten states for the purpose of measuring the return on investment in the establishment of No Wrong Door systems.  This is an exciting opportunity for both ACL and states to start to learn what should be measured, what systems need to be in place to capture the data related to those measures, and to validate what types of processes or interventions are most likely to lead to desired outcomes, one of which is mostly certainly delaying the need to access publicly funded services.  It might be a little late for Aunt K, but for the millions coming behind her, it might be just in time.

“We help navigate change in HCBS/LTSS by adding subject matter knowledge and experience in operations and organizational design as well as capacity to organizations (agencies, states, companies) that are implementing new programs or updating business processes.”

This is the current version of our Sage Squirrel elevator speech. After we’ve said this, we try to share our mission which is to help our clients go “beyond compliance” by focusing on operational and organizational effectiveness, creating systems that are accurate, consistent and efficient (“ACE”) for payers, providers, and recipients.  These themes carry through the experiences Debbie and I have had across government, non-profit, and business environments. This is the second in a series of blogs we are doing to elaborate a bit on our elevator speech by sharing some experiences we have had or situations we have observed.

In January of 2005, I was working in the Indiana State Personnel Department.  The incoming governor came into office with a change-driven agenda and the desire to make government work like business.  I was in a terrific position to watch and participate in some key initiatives.  One of his goals was to transform how workers were appraised and how pay raises were distributed.

Up until that point, raises were across the board and there was little that people could do to move through their pay grades.  Performance appraisals were perfunctory at best and the process was largely perceived as an exercise in documentation.  I was tasked with updating the forms that were used.  This turned into a much larger project because performance management isn’t just about the form – it is about the definition and understanding of performance and how individual performance related to overall organizational performance and how that can drive continuous improvement.

This required culture change and some agencies were more successful than others in navigating that change.  The notion of “SMART” goals was foreign to large number of managers in state government at that time, including a lot of executives.  We conducted an extensive campaign of education and communication, starting in cabinet meetings and then meeting with all agency heads and division directors.  I was stunned at the numbers of agency leaders who said that the idea of performance was irrelevant to the work that they did.  They insisted that their roles were regulatory in nature, that they were not accountable for anything but compliance.

Why do businesses do business?  Because they can make a profit doing so.  When they are unable to make an adequate profit, they adjust – they cut costs or they increase prices, or they work to increase revenue through increased sales.  That profit motivation drives ongoing innovation and a constant quest for increased efficiency and continuous improvement that is a hallmark of operational effectiveness.

Why does government do government?  There’s no way that I can reduce that to an easy answer, but I can tell you for sure there is no profit motive in government.  Government does many things that the private sector would NOT do because there’s no profit in it.  Public safety and rural postal delivery come to mind as examples where the private sector might take a pass.  Child welfare might be another one. Government does these things because they have to be done.  Government, regardless of party, has a responsibility for ensuring the safety, liberty, and some measure of well-being of citizens. It’s part of the pact with citizens in exchange for the taxes we pay.

I don’t want to paint with too broad a brush here, but I think it’s fair to say that government does not always do things as efficiently as possible. I think it’s also fair to say that government is not always good at measuring the effectiveness of what they are doing and whether or not they are actually achieving stated policy outcomes. To me, that’s unfortunate because doing these things is also a big part of the pact with citizens. I think it’s fair to expect that the government should collect no more than what is actually needed in taxes and that they should do everything possible to make sure that those monies are spent effectively and efficiently.

There is a tremendous amount of subject matter knowledge in state governments – you need that subject matter knowledge in order to craft policy that supports the above outcomes.  There is also a tremendous sense of mission in most of the public servants that I have worked with.  Most are working in the public sector because they want to contribute to a greater good in some way.  What is in shorter supply in state governments are managers that have the skills to evaluate and facilitate ongoing and rigorous improvements in efficiency and effectiveness in the operations that support those policy outcomes. (the reasons for this are probably the subject of another blog!)

What you end up with are systems and processes that are built around compliance.  These are usually systems or processes that are built within programmatic or functional silos.  They are frequently not user-friendly for external users.  They almost never support person-centered practices, nor do they facilitate going beyond compliance in service to larger objectives.

Businesses also operate in a complex regulatory environment. Most successful businesses find ways to incorporate regulatory compliance into the success of their business mission.  A simple example –food-related illnesses are terrible for restaurants.  Conducting food safety checks is one way to ensure that their food does not cause a food-related illness.  Documenting those checks is a defense against claims of food-borne sickness. But the success of the business is still measured by its ability to survive and generate profit.

Compliance is a floor. In the LTSS world in particular, compliance alone is not enough to meet the challenges of growing demand, exploding expenditures, evolving regulatory requirements and changing consumer preferences. But sometimes organizations, particularly government agencies can get tunnel vision around compliance.  Human service agencies must address organizational fragmentation, funding siloes and ineffective business processes. It doesn’t matter if you get the policy right if operations and implementation are not effective. You have to go beyond compliance.

thinking2We have a couple articles on the topic of person centered planning that may be of interest.

Person Centered Counseling and No Wrong Door

Person Centered Planning and the Settings Rule

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

Assisted living is often a critical component in LTSS options. Many states funded it through Medicaid. The CMS Final Rule on HCB Settings from 2014 and the more recent GAO report have put a spot light on assisted living. We will have more on this topic in coming weeks but this piece considers the need for appropriate health and safety monitoring while maintaining a home and community based setting.

Assisted Living

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

A fresh perspective on Older Americans Act reporting and data……..


#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

Since forming Sage Squirrel Consulting, we have naturally been asked “what do you do”?  We have struggled a bit to answer that succinctly, so before we went to the HCBS Conference we drafted an “elevator” speech – the commercial we can deliver in about 30 seconds:  We help navigate change in HCBS/LTSS by adding subject matter knowledge and experience in operations and organizational design as well as capacity to organizations (agencies, states, companies) that are implementing new programs or updating business processes.

Sometimes we are still met with a blank stare which just baffles us because it seems so clear to us., Maybe people don’t always know what we mean by “operations”. We aren’t policy experts; we aren’t experts in reimbursement or rate methodology, and we aren’t an IT solutions provider.  We don’t appear to fit into any of the functional buckets that LTSS consultants get pegged into. We do understand policy; we are well versed in reimbursement methodologies; and we have implemented an IT solution or two along the way; but – we see all of those things through the lens of operations.

I don’t have a great ready-made description of what constitutes operations, so I went to Wikipedia.  Here’s what they had to say: “Operations management is an area of management concerned with designing and controlling the process of production and redesigning business operations in the production of goods and services.  It involves the responsibility of ensuring that business operations are efficient in terms of using as few resources as needed and effective in terms of meeting customer requirements. … The operations function requires management of both the strategic and day-to-day production of goods and services.” What’s so hard about that?

In the private sector, it’s pretty easy to see the goods or services are that are being produced.  It’s a widget, or a banking transaction, or a burger.  Companies have a clear interest in producing them as efficiently and effectively as they can; the alternative is costly.  Inefficient processes are expensive and result in poor customer experience and lost revenue.  Most private sector companies work continuously to stay efficient and effective, updating business process and technology on a regular basis to be competitive.  It really is change or die.

It’s not always as clear that government has an interest in effective operations, because it’s not always clear that government HAS operations.  With a few exceptions, government (at the state and federal levels) is rarely seen as the provider of services, but rather as the funder and overseer of how services are delivered.  Government may be the gatekeeper to the receipt of services; or the quality assurance monitor that accompanies the receipt of services.  When people look at government services, they rarely see a “customer” the way the private sector does.  Government processes often may be seen as wasteful and inefficient – sometimes because of regulatory requirements, sometimes because of what are perceived as bad employees, ineffective bureaucrats.  Government employees sometimes get a bad rap in the operations department.

That bad rap is largely undeserved, in my opinion. I’ve had the great good fortune to work in Indiana state government with a vantage point that allowed me to see across most state agencies.  I’ve also met and worked with a large number of people from other states and federal agencies through NASUAD.  The overwhelming majority of individuals that I have worked with have been dedicated public servants who are trying to do the best job that they can.  Many of them simply aren’t equipped to think about operational opportunities and challenges and most of them are working in a culture that is focused on compliance over effectiveness and efficiency.

There are a lot of good reasons that government is not as nimble as the private sector.  Governments do not generally face competitive pressures to stay current; in fact, governments may need to be perceived as stable by citizens in order to preserve the public trust.  The lack of financial resources and complex statutory and regulatory requirements can make keeping technology and processes up-to-date very challenging.  There is also some inertia associated with the fact that government leadership changes on a regular basis.  New leaders come in who want to make their policy mark while the day-to-day operational running just keeps on running the way that it always has by people who aren’t challenged to change or improve, or even empowered to do so.

There’s a belief in some circles that operational inefficiency is a deliberate ploy to impede people’s ability to gain access to publicly funded services for the purpose of limiting expenditures.  This is a false premise.  The overwhelming majority of public employees are truly public servants who are working to have an impact on the greater good and to serve their states.  If they are in human services, it’s nearly always to improve the lives of people who are vulnerable or less fortunate.  You simply cannot over-estimate the power of an entrenched bureaucracy in a culture that values compliance and stability above efficiency and customer experience. Some new leaders come in with a desire to impact that culture, but in an arena dominated by the electoral cycle, rarely have the opportunity to stay long enough to impact the larger organizational culture.

Debbie and I are of the very firm opinion, however, that it doesn’t have to be this way.  Government does have customers – they are called citizens.  Citizens have every right to ask for timely and efficient processes – in their Medicaid application determinations, their license plate transactions, in the payment to the providers that the state relies on to provide direct care and other services.  They have the right to expect consistency and accuracy in transactions that impact their lives, like child welfare investigations, or the determination of eligibility for services, or the enrollment of a new service provider. Competitive pressures in these areas may be limited, but efficiency and consistency are hallmarks of effective governance, and all of us as taxpayers expect government to be both efficient and effective in the use of our resources.

Given the centrality of operational excellence to the mission of Sage Squirrel Consulting, through this blog, we are going to expand on our “elevator speech” over the course of the next few weeks.  We might need a bit more than 30 seconds for our “elevator speech”!  Going up?

#SageSquirrel, #BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness

cropped-91B3D4A1-134B-4C7A-BA02-50D006F6BFD4.jpegHere is another one of our In a Nutshell issue briefs. This time we talk about EVV and the potential to go beyond compliance and make EVV an effective tool in quality assurance and monitoring.

Electronic Visit Verification

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness

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.

cropped-91B3D4A1-134B-4C7A-BA02-50D006F6BFD4-6.jpegWe will be participating in a couple of webinars with the PASRR Technical Assistance Center in August and September on PASRR transformation in Indiana and PASRR as a part of No Wrong Door. First one is August 14, 2018 and the second one is September 11, 2018. 

Check out our In A Nutshell thoughts on PASRR and No Wrong Door and be sure to join us for these webinars – info on the PTAC website.

If you haven’t seen them yet, In A Nutshell is a series of one page documents offering the Sage Squirrel perspective on LTSS topics. A number of them are on our website already. We will be adding them to our blog page too; so, if you subscribe to our blog, In A Nutshell content will be emailed to you as well. Just enter your email address on our webpage. Or just let one of us know you want to be added and we will take care of it for you.


#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness

My dad was diagnosed with Stage III lung cancer at the age of 74. He lived for about 18 months following his diagnosis and passed away in February 2012. During this time, my siblings and I became his caregivers. It was both the most stressful and most rewarding work I’ve ever done – it varied sometimes hour by hour which was which!

There came a day when his care needs exceeded what we felt capable of and we asked him to move into assisted living. He was reluctant, but he recognized that he might not be as safe as we all wanted him to be at home so he agreed to give it a try. We fairly quickly got him moved into a building that I was familiar with – in particular, I liked the staff there and thought that they would take good care of him.

I was so hopeful that this would be a good fit for all of us, but it turned out to be a bit of a disaster. Three months later, when my brother and sister went to pick him up to bring him home for Thanksgiving dinner, he was nearly all packed up and announced that he would NOT be going back. When I took him to his next round of treatments and appointments, he told everybody that he had “gone over the wall” and compared it to a prison escape.

He chafed at the requirement that he sign in and out every time he came and went from the building. He could not take his PRN pain meds on his own schedule because the nurses insisted that they were the only ones that could dispense those to him. His eating schedule became dependent on the medication administration schedule and he lost weight when he couldn’t eat when or how he wanted to. While he had a kitchenette in his apartment, staff preferred to do medication administration in the dining room so he went down there despite his preference to eat in his own apartment. His one great interest at the time was conducting online genealogical research and the facility never completed the promised wiring repair so that he could do that in his apartment. When he tried to use the communal machines, he was subject to time restrictions.

I’ve been thinking a lot about this experience lately after reading the story about the 92 year old woman who shot her son because he wanted to move her into assisted living. It actually wasn’t super-clear to me whether or not he had intended to move her into assisted living, or into a skilled nursing facility because those terms were used interchangeably in the coverage of the situation . This is not the first time that I’ve seen those terms used that way.

I’ve seen some gnashing-of-teeth industry articles about the AL “image problem” and calls for more consumer education about how assisted living is really different from nursing facilities, but I’m not sold that this is just an “image problem” or that the solution really is just to better educate consumers. I believe that there may be some real challenges to the AL industry to differentiate itself from nursing facilities.  Some of this may be self-imposed; some may be driven by state regulations. I’m not even sure that there is real consensus about what the term “assisted living” connotes.

At the time of my father’s illness, I was not educated enough to recognize that there are two different types of assisted living in my state. Both call themselves assisted living, but some of them tout that they can ensure better quality because they are licensed by the State Dept of Health. They were in fact, licensed as residential care facilities (RCFs) under the same statute and rules as comprehensive care facilities (aka nursing facilities). My father was in an RCF that marketed itself as assisted living, but in our experience, the assisted living apple did not fall too far from the nursing facility tree.

I can see how this could be characterized as a one-off – perhaps he was just an individual who was not a good fit for assisted living. Just one person, one family’s experience cannot characterize a whole industry. But my experience did not end there. In 2014, I became the Director of the Division of Aging in Indiana. Just as I began what was to become an incredibly steep learning curve in my new job, I learned of the new CMS Final Rule on Home and Community Based Settings, i.e. the Settings Rule. As we worked over the years to come to understand the rule and its implication for Indiana, I had the opportunity to visit several assisted living facilities in Indiana, licensed and unlicensed, and learn more about the experiences of individuals living in these communities. I found my Dad’s experience was not so unusual. The unusual part was that he had the option of going over the wall and back home with family again. So many people find themselves without options.

I have met a lot of AL staff, administrators and owners during these last several years. Most of them care about their residents and about providing a quality service. AL, congregate residential options in general, are a vital piece of the long-term care spectrum. I knew the community my Dad moved into. I knew it was a quality facility and the staff really cared about the residents. I knew the building was well maintained. Dad got the care we were paying for and I felt better because he was safe, and people were looking out for him.  But Dad wanted more. He was a capable adult who wanted to control his own life and his own schedule and who doesn’t want that? Why should any disability or impairment including those that come with age take that dignity from people?

The people caring for my Dad did not take away his autonomy intentionally. Neither did I. We were just not focused on helping him hold on to it. The Settings Rule is an opportunity for states and providers to do just that. As I worked on Settings Rule compliance in Indiana and as I work with states and providers now as part of Sage Squirrel, I will be remembering Dad going over the wall.