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
When I was my father’s caregiver, I frequently felt alone and confused. I didn’t always know the best way to support him, or how to navigate the murky waters of LTSS. I had heard of Area Agencies on Aging, but I thought that they were just for poor people who needed Meals on Wheels. I didn’t even know enough to ask the right questions – I tended to conflate home-based services with in-home palliative or hospice care. His doctors’ offices weren’t any help at all – they each wanted to pass me on to the other ones without answering any of my questions.
My dad may not have qualified for Medicaid, but we still could have used assistance with understanding the system, what our options were, and how to piece together a plan for supporting both him and me (that may not have led to his disastrous stay in assisted living described in previous post!). We needed information to make good informed choices for his long-term care needs. I didn’t know to even try turning to a AAA for that assistance. I’ve certainly learned a great deal since then!
Since that caregiving experience, I have come to be a real fan of the AAA network, or, to be more accurate, the potential of the AAA network. Since the creation of the aging network 50 years ago, AAAs have been the vanguard in identifying challenges that the aging population faces and in developing solutions to those challenges. They were addressing the social determinants of health before that term became so commonly used.
Their experience in person-centered options counseling and community-based case management equips them to be natural partners to health care systems seeking to improve outcomes associated with transitions of care, or caregiver support. Their potential for community partnerships and referral experience made them a natural fit as Aging and Disability Resource Centers (ADRCs) in many states. As such, it is also natural for them to have a prominent role in state No Wrong Door systems. Many function as the entry point to Medicaid-funded LTSS, but it may be more important that, through person-centered options counseling, they have the potential to provide access to less costly, earlier interventions that may prevent or delay the need for Medicaid-funded services.
Some AAAs are already forming robust partnerships with healthcare partners that are proving fruitful for both parties. Some AAAs are working to gain business acumen skills to develop their abilities to get those contracts. These are successful individual organizations, but not necessarily successes for the network as a whole. We were just at the n4a (National Association of Area Agencies on Aging) annual conference last Monday. It was great to celebrate the individual success stories, but the continual use of the word “network” seemed to imply that all AAAs were performing similar activities, and almost obscured the fact that many AAAs are really struggling just to stay afloat.
Aristotle said, “the whole is greater than the sum of its parts.” I believe that is true of the potential of the AAA network in any state. I think it was also Aristotle that said, “the worst form of inequality is to make unequal things equal.” In my observation, AAAs don’t’ act as a true network and some of this may be due to the fact that there is such variation among them in capacity, skill, and mindset.
At the n4a conference we also heard Lance Robertson, Administrator and Assistant Secretary for Aging, speak about the future of the network and the potential opportunities for building a stronger network. He (very politely) challenged them to move forward and indicated that not all may be able to. A couple of his tenets stuck out with me as particular parts of this challenge: the need to acknowledge and address weaknesses; the need to fight against the scarcity mindset; and the need to encourage each other. The scarcity mindset in particular, I think, leads to an organization making it someone else’s responsibility to “fix” their inabilities. It goes hand in hand with an unwillingness to self-examine one’s organization and honestly identify and be willing to address areas where improvement is needed.
The ACL and the state units on aging are also critical components of this aging network and share some responsibility for facilitating, supporting and challenging AAAs to grow and change. As a manager and an executive, I have always sought to raise the bar for my team or my organization. Raising the bar in terms of expectations for performance, for real outcomes, can bring out the best in some. There will be those than cannot rise to the challenge. States can be good managers trying to raise the bar for their AAA networks by:
- Defining desired outcomes;
- Setting clear expectations;
- Measuring performance/outcomes; and
- Creating systems of accountability with consequences.
The network’s strength depends on everyone’s performance improving – the strong ones pulling the weaker ones up. Those that can’t reach the higher bar cannot be allowed to hold the rest of the network down. Whether it is a managed care entity, a health care system, or a state building capacity in their LTSS system or creating a No Wrong Door system, they all need a AAA network that is strong, not just a few strong AAAs defining their own success.
States and payers can and should be investing in their AAA networks. The ACL has certainly provided tools and resources for the aging network to foster this – the business acumen development resources, the investment that has been made in No Wrong Door (including the current grant opportunity around RoI). AAAs must begin to understand and accept that increased opportunities also come with the increased expectations and requirements and to find ways to work together in meeting those.
I want to believe that if I had known and made the call, I would have received the help I needed; but I am not sure that individuals and caregivers in similar situations can make that call and consistently get the help they need. I fear it depends too much on which AAA they called. That’s not a network. That’s not a system where the whole is truly greater than the sum of its parts … but it could be. I believe in that potential and believe it’s worth working for.
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