Christiaan's Perspective

I was reading a journal the other day, and was struck by a quote defining the term “Change Function.” This was defined by the moment when a perceived crisis is worse than the perceived pain of adoption. How well this relates to organizations that serve people with disabilities! As we are generally caught between the need to innovate and the need for stability, “best practice” tends to fall somewhere in the middle. Our consumers, as well as our employees, tend to be most comfortable with the maintenance of the status quo. Any change is best done slowly, and with great care that it does not undermine service quality by failing to identify an unintended consequence.

Technology is available that can greatly increase the efficiency of provider operations. Electronic documentation, timekeeping, and new models of service are available that are much better and faster for gathering information and using it effectively. Compliance with State and Federal regulations can be assured by building them into the systems themselves. More time can be spent in direct support when less time is devoted to burdensome documentation. Still, in light of this, most providers stay with paper based systems, focus on programming areas that have not changed in decades, and devote very little time to trying new approaches to service. When innovation is critical, providers tend to look for existing models that are newer than the model they currently embrace.

I think the reason for this is two-fold. First, providers have an enormous amount of rules, regulations, laws, and cultural beliefs that must be observed. If an existing system has made it through a few audits, and everyone seems OK with it, there is an enormous perceived risk in changing anything about it. When change is forced (by new regulations or beliefs) there is a tendency to change just the area in question, forcing new information into old models. The other reason to avoid updating systems, especially electronic systems, is that in recent years there have been massive shifts in billing and documentation requirements handed down by the state. There is a lot of risk in purchasing systems at high dollars that may be obsolete within months.

The one unavoidable fact of being a provider in Indiana is that the cost of providing services and the amount of needed service will continue to rise, while the available revenue to pay for it will shrink. We are indeed entering a “Change Function” period. The system must change and grow, and people must be served. It is critical that the State and providers work together to find a solution. Providers want to do the best job they can in meeting the needs of consumers, and the government is responsible for assuring prudent expenditures of taxpayer dollars. I do not see these priorities as being in conflict. The system we are transitioning into right now is clearly broken, and many providers are in danger of closing their doors. Some are responding by demanding a freeze of all change, in favor of the status quo. Others are attempting to negotiate, with little success. Most are just keeping their heads down. Here are the facts as I see them:

1. The world is changing, and the way providers do business must also change.
2. Standardized rates are absolutely necessary for a level playing field, and they must cover the expense of providing that service.
3. Providers really do more about providing services in their field than state officials. This is not meant to be an insult, but a statement of fact. An agency with a 50 year record of quality service will know how to do it better than any administration. Compare and contrast State-run institutions and community-based providers for numerous examples (of both programmatic quality and cost effectiveness).
4. Any system that adds complexity adds cost. Simplify and excel.
5. Providers will be able to identify ways to reduce costs if a system is in place long term. Innovation cannot happen is an environment that is always in “beta.”
6. Providers will need time and capital to purchase and develop systems that are more efficient. This will save money in the long run, and will allow a shift in expenses from overhead to wages for DSP’s.
7. Providers and the government must work together as partners to make things right. There should be discussions with known quality agencies, not just the largest ones. A positive response from a provider serving 10 counties does not balance a negative from 10 providers serving a single county. Urban and rural providers must both be polled.
8. State policy and provider expectations should not be reduced to the lowest common denominator. It is a regular event for a rule for all providers to change in response to the bad behavior of a single provider. This stifles innovation. Providers who break the rules should be called on the carpet instead of being buried in an overall environment change. To swipe a phrase from my CEO, “That is eliminating islands of excellence in favor of a sea of mediocrity.”
9. There are already established service fees that are uniform in Indiana. These are set legislatively and are on the books. This is a good starting place.
10. Non-profit agency financials are public record. It is a very easy thing to verify that taxpayer dollars are being spent wisely and appropriately. By encouraging for-profit companies to be transparent with state dollars as well, there can be a true grasp of the costs of service provision, and funding mechanisms can be tailored to support them.