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. 

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.

When my dad was dying of lung cancer, all I wanted to do was wrap him in bubble wrap and keep him safe. When he started falling, especially.  All he wanted to do was stay independent in his own house, even if it meant falling sometimes. It was difficult to come to some level of agreement with him about how to balance what we both wanted, but ultimately, as a competent adult, his wishes were paramount, not mine.  My focus on his safety felt like I was trying to limit his movements, rather than trying to find ways to support his desire to stay independent with other ways to mitigate his risk.  At the end of the day, it really was his decision as to how much risk he wanted to assume.

He was a reasonable person and understood that there was a point at which it was too much risk, but he chafed at that.  When we tried assisted living, he ended up moving out after a few weeks, telling everyone that he “went over the wall”!  Ultimately, he ended up going to my brother’s house for the holidays and stayed until he started hospice a few weeks later subsequently passing away peacefully in my brother’s home.  But he was contemplating independent living right up until the week before he entered hospice.

The balancing of risk and autonomy and the assumption of risk is experienced along a spectrum in long term care. The default LTC option in many states is still nursing facility care.  While there are some efforts being made to help nursing facility care be more person-centered, the general expectation is that the institution is nearly 100% responsible for what goes on while a person is in their care; choices are limited; and the provider directs a large number of decisions about how residents experience their day to day lives. People reside in these facilities with staff available 24/7 and nursing facilities are at high risk of liability for anything that occurs while a person is in their care.

People who receive their care within a private house or apartment assume the greatest amount of risk.  In many cases, there is no need for a 24/7 caregiver to be present in the home and the person is free to come and go around their house, yard, neighborhood or community to the extent that their mobility and resources allow them to do so. While steps can be taken to mitigate some risk, they can still fall, or they can make a mistake with their medication, or they can have any number of other things go wrong.  One of the documents they sign when they start receiving HCBS waiver services is an acknowledgement of risk form.

The assumption of risk question is less clear in settings like assisted living. In theory, these are home and community based settings and the assumption of risk falls to the person. In practice, the expectation is that the providers are assuming responsibility for their residents.  This assumption is made in many cases by the provider and by family members with expectations that their loved one will be just as safe in assisted living as they are in a nursing facility.  It is unclear to me whether or not assisted living is just a less restrictive form of institutional care, or if it is community based care in a congregate setting with supportive services.

This is not a theoretical question.  Assisted living is one of the fastest growing services in long term care, particularly for persons living with dementia.  Many states fund assisted living as a Medicaid community-based option for persons who might otherwise reside in a nursing facility.  Regulation of assisted living varies widely from state to state.  Some are licensed; some are licensed residential care facilities; some are unlicensed.  Multiple states are having conversations now about increasing licensure requirements as a means of assuring safety for residents.  There was a recent GAO report on safety and oversight for persons who receive Medicaid-funded assisted living services that has led to Congressional attention.

This discussion of improving or increasing safety and oversight in assisted living is happening at the same time as states are seeking to implement the HCBS Settings Rule which very clearly sets out regulatory requirements for settings that participate in Medicaid home and community based programs. These requirements are based in maximizing individual autonomy, privacy and choices within their day-to-day lives so that they can receive the full benefit of remaining in the community rather than moving into a nursing facility.

States are the party responsible for making assurances to CMS about safety and well-being of Medicaid participants in home and community based programs.  There are several ways that states do this, but the major one is reporting and tracking of critical incidents and remediation of factors that lead to critical incidents.  The conclusion of the GAO report is that states may not have systems that are as robust as needed to do this adequately.  We anticipate that states will be looking at this closely (possibly with some help from Congress) over the coming months and years.

So states are facing that same balancing act of mitigating risk while facilitating maximum autonomy for persons who receive Medicaid funded long term services and supports outside of nursing facilities.

The apparent dichotomy of “important to” and “important for” in person centered thinking is not an either/or situation. It is a balance. It is possible to have to have both in measure. We all decide everyday what is acceptable risk. Why should expect to give up that autonomy as we age or battle disease, disability, or other impairments? States, providers, funders, advocates, families, and consumers must all work together to reimagine how we provide long term care, finding ways to mitigate risk and preserve autonomy. We should not have to sacrifice one for the other. We can balance individual choice in home and community based and institutional settings with appropriate levels of oversight and accountability. Many us, have worked, or are working to find that balance for our parents; all of us want that balance for ourselves someday.

When I was a fledgling shift manager with McDonald’s I attended a basic operations training class.  I don’t remember much about that class, except the one lesson that has stuck with me for my entire management career.  Thirty years in the telling, this is a multi-generational paraphrase of a concept originally presented by Dwight Eisenhower, but the essential message remains.

The instructor compared management of people to trying to move a piece of string.  You can move the string by pushing on it, but it will begin to curl up on itself and become more difficult to move it in the desired direction; but if you pullthe string, you can take the string anywhere you want to go.

I don’t remember making the conscious decision to be a string puller, and not a string pusher, but this lesson ultimately became the basis for my approach to leadership and management.  I’ve been able to apply it at every level – from managing individual crew persons in a McDonald’s restaurant to leading larger groups of professionals, and managers in their own right, to collaborating with external entities that are part of the systems I have worked within.

To me, “pulling the string” means creating shared vision, harmonizing goals and objectives (and/or demonstrating shared interest) and then clearing the path so that the individual, or the team, can accomplish that shared vision.  Coaching and appreciating along the way are all part of pulling the string too.

Management is the art (not science) of harnessing and coordinating activities and resources in order to achieve a defined objective.  Of course there is more to successful management than pulling the people string; but usually the most important resource that managers are harnessing and coordinating is their people.  Practicing effective employee relations is a core management skill.

String pushers are frequently the managers who say, “I shouldn’t have to show my appreciation that way – this is their job and they just have to do it in order to get paid”.  String pushers may be more likely to spend more time on rules and discipline than on coaching and appreciation.  Hard core string pushers may describe other approaches as “soft” or as too “touchy-feely”, but I have had the great good fortune to work with some very high performing folks – there was nothing soft about what some of these people were accomplishing!

String pushers aren’t necessarily bad managers, but I always saw pushing on the string as a lot more difficult than pulling it. It gets us all where we want to be with a lot less friction and resistance, and frankly, pulling the string is a lot more fun!

The long term services and supports arena is facing a workforce crisis. There are less workers available to provide care or support to people who need it, but the numbers of people who need that care and support is on the verge of exploding.  High turnover and high levels of absenteeism are rampant across all sectors of long term care.  (Check out the workforce related “In a Nutshell” issue brief at www.sagesquirrel.com). Providers, payers, policy makers and regulators have a shared interest in supporting workforce development, including strategies that promote the recruitment and retention of high quality direct care workers.

There are a number of studies that have demonstrated that the leading reasons for people leaving their jobs have more to do with how they are treated than with how they are paid.  Of course, we can’t discount Maslow’s hierarchy, but once you are past that basic threshold, most people leave because they aren’t treated like they would like to be treated.  I remember a not-for-profit nursing facility that had lower wages than any of the surrounding facilities, but their turnover was a tiny fraction of the turnover in the surrounding area.

Turnover is costly – and it can breed a very difficult cycle and lead to a lack of willingness to invest resources in the front line workforce. But stabilizing that workforce can lead to reduced costs associated with turnover and providers may then be more willing and able to invest additional financial resources as well.

The long-term care workforce is a scarce resource. Managing effectively and fully engaging your workforce in every care setting is critically important to managing that resource. All types of long term care providers rely on valuable human resources: nursing facilities, assisted livings, adult day centers, home health agencies, and personal services agencies. Challenges may be different in each sector but the principals of good operations and people management stay the same.

Long term care of any type doesn’t happen without the caregivers.  Companies say all the time “our people are our most important asset”.  One of the ways that this can be demonstrated is finding ways to pull that string, leading people, not pushing them.

If you had walked into our former workplace, you would have seen an unexpected sight – at least for a government office – unicorns everywhere!  Usually purple but all unicorns were welcome. They had become the mascot of the Division of Aging and it was all related to person-centered thinking.

I had not really heard the term “person-centered” until right after I joined the Division, when the HCBS Settings rule was promulgated.  I won’t claim that I fully understood it (then or now!), but my understanding of what being person-centered means has grown through our experience in facilitating the creation of Indiana’s No Wrong Door plan, throughout our work to implement the Settings Rule, and our approach to the overall modernization of LTSS in Indiana.

Person-centeredness is at the core of any high-performing system of LTSS, but it’s a concept that is easy to misunderstand, much to our shared detriment.  I think that to people seeking to bring a business orientation to publicly funded LTSS, it sounds like a “touchy-feely” social service concept. Budget people are wary because it sounds like the payer is expected to do/be all things to all people, and that’s a scary fiscal concept; but there are good business reasons to develop a person-centered culture.

A traditional eligibility-driven system starts with the question of “what are you eligible for?” People may then be offered everything that they are eligible for. The eligibility gate, in theory, is intended to restrict services only to those persons who meet criteria, but it also may result in people receiving services that they are eligible for whether or not those services actually address the challenges they face. Additionally, persons may be directed to use their personal resources in such a way that it drives them to eligibility faster than they might otherwise have done.

Information shared by ACL in 2014 suggests that about 80% of people who inquire about LTSS can have their needs met without using public funds –  but– the system has to be able to determine what those needs actually are.  There are more questions in a person-centered system:  “what challenges are you facing?”, “what do you need?”, “what resources currently support you?”

Person-centered counseling starts with figuring out what a person’s actual challenges are and what resources, financial and otherwise, they already have, even what community resources might be available.  For example, people can be counseled on ways to use their personal resources to remain in their home, or it may be ascertained that their need is really caregiver support to sustain and preserve their caregiver’s ability to continue to provide care.  If there are gaps, then eligibility can be determined and publicly funded services can be implemented to fill those gaps.  People may delay needing Medicaid if their support needs are met in a more targeted fashion, and/or if they have support to develop strategies to remain in their home using their personal resources. People need information so that they don’t just have choice – they need to have informed choice.

No Wrong Door systems are the most recent evolution of the effort  by ACL and CMS to support states in developing person centered systems of access to LTSS. It’s a paradigm shift for many states that may require a significant investment to design and implement. The business case for developing NWD has been challenging because it’s been hard to figure out how to measure the return on the investment that may be needed in many state LTSS systems.  The recent NWD funding opportunity from ACL is a chance for states to collaborate with ACL on data collection strategies and measures development for the next two years.

While it is comparatively easy to identify process and output measures or documentation associated with person-centered activity, it is still not truly easy to know whether or not those activities have become absorbed in the culture of the organizations in the system – that there is a true framework for person-centered thinking, counseling and planning.  Ideally, this way of interacting with participants is fully integrated in all aspects of how the system works, not just the how we work with those seeking or using LTSS.  That was our (admittedly ambitious) goal when we embarked on the development of a learning community for person centered practices in Indiana.

Understanding of what person-centeredness means varied widely across Indiana.  It was almost easier to explain what it wasn’t than what it was.  A case manager observed one day that “person-centered meant taking people’s opinions into consideration when they developed their plan”.  Some compared it to just really good customer service. Another case manager stated in a training “Person-centered planning means giving people everything that they want – and we can’t give them everything that they want.” Debbie responded that she was right – we couldn’t give people everything that they might want.  She told her that “they might want a purple unicorn and that we were never going to be able to give them a purple unicorn, but that it was still important that we understand that this was important to them and learn about why it was important”. Person centered planning is often the art of balancing what’s important TO a person, with what’s important FOR that person.  The result is targeted services that address specific needs rather than an eligibility focused process resulting in service selection from a menu of what is available. But the entire system, from intake to service definitions, to service delivery, to reimbursement, has to support that outcome.

The purple unicorn became our reminder of the importance of person-centered thinking and the need to put individual goals, needs, and preferences ahead of eligibility determination. The purple unicorn was our (just slightly subversive) symbol of putting people at the center of the processes, rather than just expecting people to conform to existing processes.  They had become the de facto symbol of the system transformation we had undertaken.  While sometimes visitors raised their eyebrows, we were always happy to explain the legend of the purple unicorn.

To state the obvious to many who might read this, the world of LTSS is highly regulated.  Federal grants have multiple reporting requirements to ensure that the funds are being spent appropriately. Nursing facilities operate in an incredibly complex system of regulations designed to ensure that residents are safe and that they are receiving quality care. In Medicaid-funded HCBS, CMS requires numerous assurances about the type and quality of services being provided and how the state is ensuring that participants are protected from abuse, neglect and exploitation. Rules and regulations can also create shared definitions, shared goals, and level playing fields for providers.

Everyone would agree that health and safety and protection of individual rights are worthy goals; however, it can become very easy for these rules and regulations to take on a life of their own. Compliance driven processes are created and the original intent can get lost.  Compliance itself becomes the outcome. In some cases, performance and quality measures are equated with compliance rates.

We have had the enormous good fortune to work with highly dedicated and mission-driven public servants through the years, but we have also seen compliance-focused organizational culture and business process impede quality improvement and necessary change time and again. It shouldn’t sound radical to propose that compliance is a floor and regulations are an opportunity, but it feels a bit radical!

While compliance is a good (or even a great) outcome, it should not be the only outcome. Processes and systems can be designed to maximize compliance, ensure outcomes consistent with policy goals, and achieve operational excellence.

It is easy for highly regulated environments to stagnate. Building in continuous improvement to the program or process design may alleviate this risk and create opportunities for periodic review. Creating operational excellence focused on accuracy, consistency and efficiency, can create expectations for both compliance and effectiveness and can mitigate building in unnecessary compliance-focused redundancy.

Ensuring that each individual in the process clearly understands the policy objectives and performance goals associated with a process can mitigate the tendency for a system or process or report to be done “just because it’s required”. It is also a great opportunity to empower individuals with the tools and knowledge that they need to support efforts to continuously review and improve operations. Continuous quality improvement happens when everyone feels empowered to ask “why”!

Regulatory requirements at both the state and federal level are updated, or new requirements are introduced on a regular basis. Each of these changes is an opportunity for positive change. In compliance-driven systems, change is feared because of the need to learn new ways to manage a process or system and still be compliant. Instead changing regulations can be a catalyst for change, an opportunity to reevaluate “how it’s always been done”.

When quality assurance is perceived as something that is completely different from, or separate from, quality improvement, systems can be fragmented and more expensive. While these are separate concepts, they can be developed and implemented in tandem with each other to achieve better outcomes and improve efficiency, leading to administrative savings.

Sometimes a fresh perspective helps to recognize the positive potential that changes in regulatory requirements present to your systems – or the fresh look that is created when you have new eyes looking at your system. The same kind of opportunity is created by the development and implementation of new technology.

We are doing a series of issue briefs: “In a Nutshell:  Fresh Perspectives on LTSS Issues” to outline our thoughts more specifically about what these opportunities look like and how to capitalize on them when they present themselves. The first one up is about the promise of PASRR to support policy objectives such as Medicaid rebalancing, or Olmstead planning. More are planned on topics like Electronic Visit Verification, the HCBS Settings Rule, NAPIS reporting – the list could go on and on! Of course, we would love to be that set of fresh eyes for any organization that is trying to figure out how to leverage the opportunity to go beyond compliance. Check us out at www.sagesquirrel.com!

I started working at McDonald’s to put myself through college. For a few years it was part-time supplemental work, but I quickly went into full-time management. When I finally left I was overseeing multiple locations for a franchise owner.

My mantra was to leave my store at the end of each day better than it was when I walked in.  This is what I asked of my team too. During my time as General Manager, we ended up turning around an underperforming store from bottom of the company ranking to the top, across nearly all measures.

There were times in the controlled chaos of a high volume shift – I would be coaching for faster service times, or improved grill production and I would have this weird moment of awareness about the fact that this was all just about hamburgers and why were we getting so excited about hamburgers.

Now, it really wasn’t just about hamburgers; it was about excellent customer service and a great consumer experience, but that service and experience generally involved how fast people got their hamburgers.  My biggest motivator was how to manage my store to deliver consistently high customer service and a positive consumer experience.

Fast forward to late 2013.  I had just been appointed Director of the Indiana Division of Aging when I met Debbie Pierson. She had joined the Division about six months earlier after 11 years in an Area Agency on Aging.  Debbie had also been a restaurant manager for several years before pivoting into an entirely new career direction.

As restaurant managers, we were taught operations management, people management, leadership, problem solving, finance and, most importantly, customer service. We learned to see our stores as systems, to constantly evaluate and observe, to identify barriers, to problem solve on the fly, to motivate every employee to get the best out of them. Some of this learning took place in classrooms (yes – Hamburger University really exists!), but most of it was on-the-job training.  In these roles, we both learned by doing – by making mistakes and fixing them, or by trying things out that got the results that we needed.

Looking back, that experience taught us to put the person being served at the center of the system; and we learned the principles of managing user experience and lean business process.  We both carried those lessons on with us through each job and career change on our paths to the Division of Aging.

The timing was serendipitous.  Over the next four years, we teamed up to start the modernization of most of Indiana’s service delivery systems for older Hoosiers.  We recognized that we were in a position to transform how services were delivered to tens of thousands of people across Indiana impacting people’s health and safety and the quality of their lives.

As Sage Squirrel, our goal is to provide business solutions to meet our clients’ policy objectives. We are experienced in analyzing operations and organizations to create accuracy, consistency and efficiency to support policy goals.  We do this by applying the same skills we learned and applied once upon a time as restaurant managers – be systemic; observe and analyze; identify barriers and bottlenecks; and intervene with solutions along the way.

We want to work with partners who, like us, are sincere about putting people at the center of the programs designed to serve them.  We want to work with partners who believe that the “customer” is not just the individual receiving services, but also the providers who need to get paid, or the case manager seeking to coordinate services across multiple payer sources, or the community based organizations that need quality training n order to be able to support larger objectives.

The challenges that we all face as we seek to meet the exploding demand for long term services and supports calls for a new approach.  No one can just keep doing what they’ve been doing, the way they’ve been doing it and expect to get different results. Good policy solutions need to be supported with good business solutions.  It’s worth investing in – it’s not just hamburgers anymore.

Every now and then an opportunity presents itself and you have to seize it. That’s certainly the case with the formation of Sage Squirrel Consulting. Debbie and I have moved on from the Division of Aging, but we both want to continue contributing to the transformation of publicly funded human services and healthcare for older adults and persons with disabilities.

Most of the people who will read this already know that there are tremendous forces at play in the long term services and supports arena: baby boomers have begun turning 65 and longevity has increased for most persons born in the 20th century; the numbers of persons available to provide both paid and unpaid care are decreasing; healthcare costs are exploding, particularly for persons who need or use long term services – and 70% of people over the age of 65 will need some type of long term services and supports. This could range from a family member who helps with groceries all the way to 24 hour care in a nursing facility.

Medicaid has become the largest funder of long term care in all settings – but if all you do is read the headlines, you can see that Medicaid is at the forefront of discussions about the future of healthcare. Plus, Medicaid has a built-in institutional bias, but that bias is becoming increasingly outdated as personal preferences and legal requirements create tremendous pressure to provide needed services in people’s homes or other less restrictive settings. It’s a happy public policy coincidence that doing so, in the aggregate, is less expensive, but making that shift has been very challenging in many places.

For the last four years, we have been both participants and observers in the long term services and supports (LTSS from here on out!) arena. As the former Director and Deputy Director of the Indiana Division of Aging, we have been on the front line of Indiana’s efforts to transform systems to meet these challenges, while observing what was happening in other parts of the country.

Here are our thoughts about what it’s going to take to meet these challenges:
1. Disruption – there is a paradigm shift underway and you can’t ride that out simply doing what you’ve been doing and just trying to do it better. Small tweaks are not going to be sufficient in most cases.
2. Integration – there are silos everywhere you look, but it’s critical to recognize that they are all part of the same system. It won’t be enough to change in one sector without recognizing the implications, laterally as well as upstream and downstream.
3. Operational excellence – it is so easy in highly regulated environments to default to compliance, but compliance is a floor. If you can see those implications across the systems, what are you going to do about it? How do you leverage technology? How do you align the human capital? How will you know if you are driving the outcomes that you need?
4. Compassion and empathy – these systems should be designed around the real human persons that they are intended to serve. People are not a problem to be solved – or an object to be “put” somewhere. They are not seeking to exploit public funds for maximum gain. Many are in crisis and are overwhelmed trying to navigate the complex administrative and eligibility-focused barriers in front of them. We can do better.
5. Collaboration – there is no enemy other than those we create, and there is real positive energy created by bringing together multiple points of view in service to shared objectives. Solutions are more wide-ranging and creative.

Fresh eyes and a sense of humor helps a lot too! We aren’t policy wonks – but we don’t need to be. Most states and communities are getting their policies right, but they don’t always recognize or know how to create the business alignment in support of those policies. That’s where we can help.

A squirrel of ability and the desire to accomplish something can do anything….
#Squirrel #Quotes