A Vermont Change Agent Challenges the Paradigms of Elderly Care

Daniel Forrester interviews Patrick Flood

The following is a complete transcript of an interview with Patrick Flood, the Vermont Commissioner for Disabilities, Aging and Independent Living, which we conducted just before Thanksgiving.  Flood caught our attention with some of his extremely innovative thinking surrounding elderly care in America – how it is administered and how it is paid for.  By challenging the standards of how elderly care is conducted he managed to save Vermont millions of dollars.  The following interview offers much for other change agents to consider.

Daniel Forrester: I’m wondering if you could begin the conversation by just giving our readers context on what a day in your life is like so that they can locate you in the great state of Vermont?

Patrick Flood: Well that’s an interesting question. My department is responsible for all the services for elderly and disabled people, except folks with mental illness. So, elders, people with physical disabilities, and people with developmental disabilities–it’s pretty wide ranging. So we spend our day talking with consumers who either want services or have problems they want resolved or we spend a lot of time talking with the providers who develop and deliver the services people need. It’s pretty varied when you think about all the different kinds of folks that we deal with.

Forrester: How many customers on an annual basis interface with your department?

Flood: Well, tens of thousands. I think it’s always a little embarrassing to talk to people from other states given the numbers out of Vermont but you know we have literally somewhere around 25,000 or 30,000 individuals in this state who are touched fairly directly by the work that we do.

Forrester: And Commissioner, how long have you been in the government and can you give us some context on how you got to the job?

Flood: It’s a long and interesting story but I won’t bore you with all the details but I started out in healthcare as a nurse, actually because I was traveling around at the time and that was a perfect job for traveling but that’s another whole discussion. But my first job in healthcare was as a nurse’s aid in a nursing home and that’s what really led me to where I am today. Because even then I could see that there had to be a better way, really, to take care of our older folks. And, when I stopped, and in my nursing career I worked as a nurse in, I don’t know, probably five or six nursing homes and when I decided to leave nursing I got a job in the agency on aging which serves elders. And then a job came open in state government that had to do with handling complaints from people about nursing home care and that just seemed to me to be a perfect fit and so I took that job and over the last 20 years I’ve had a lot of jobs in the system related to services for elders and services for disabilities.

Forrester: Commissioner given your time in government and working inside the healthcare space there’s bureaucracies that occupy both of those institutions. I’m wondering if you could just generally comment on how someone who’s looking to make changes inside those types of environments — when they see an opportunity, how resistant are these cultures to change?

Flood: Well you just said about three very important things in my opinion. First of all, you talked about the bureaucracies. State government isn’t the only bureaucracy, healthcare is a bureaucracy by itself, whether you’re in a nursing home or whether you’re in a hospital, and they’re very bureaucratic settings. And bureaucracy and institutions, they seem to take on a life of their own and they often times forget why they even exist which is to provide help to people who need help.

The trick, I think, in state government is looking for that opportunity, you just mentioned opportunity, I think that’s a key word because it doesn’t always come along where you can find a chance to make a difference and change a program, or do a great innovation, but you have to see it, you have to be ready for it when it comes so you can jump on it and take advantage of it. And it is hard to change – the nursing home system, for example, has been doing business a certain way for about 35 years, since Medicare and Medicaid first created the benefit. And that’s gotten, in my opinion, more and more entrenched, rather than more and more flexible and more and more creative and it’s very hard to convince people that there is a better way and that it can be done well.

There’s a whole generation of people who grew up working in this system and doing it in a certain way and it’s very difficult to change things over the years. And it’s very difficult to change things in state government, there’s a lot of competing interests, there’s a lot of vested interests. So one of the tricks, I think, there’s really a couple of key things – one is, remind everybody what this is really about–this is about people who need help, number one. Number two, there actually is a better way to do things. One of the beauties of what we’re able to do now with long-term care is we’re able to show people that there is change which a) not only gives people what they want, but b) is more cost effective so that you capture the attention of the people that are paying attention to the budget. You just don’t find too many opportunities like that where you can do good for people and manage public monies better. So you must focus on the people and you must be looking for opportunities. You have to be able address the concerns that people have. The budget people have a legitimate concern. They just don’t have the imagination all the time to think of better ways of doing it. So, you know, creativity is a key, and you have to keep your eye on the ball, keep your eye on the prize, you can’t be daunted. I’ve been doing this, in one way or another, for over 20 years. In every step of the way I think we’ve been able to make some improvements, but there’s always another to be made, and I think you just have to keep your eye on that prize and be persistent.

Forrester: Commissioner, we find in our research that change agents have extraordinary relationships with the leadership above them that create the space for the Patrick Floods to be innovative. Can you comment on your relationship with the leadership above you and do you think they’re giving you the space on thinking about this problem in a different way?

Flood: Well they absolutely have. I’ve served four different governors in the state of Vermont both Republican and Democrat but the ones that are most important to the work that we’re talking about today was Howard Dean, who was a physician and who very early on understood that there was a better way to care for older people than to put them in nursing homes. And Howard was also a fiscal moderate, if not conservative, and so he also understood the whole idea of better care. And so our current governor is a moderate Republican but he also immediately got it. This was not only good for people; it was good for the state budget. You know a part of my job in state government is in fact to help my governors, my leaders. You have a good policy and so that they can, in fact, look good to some degree. So we’ve tried to bring this stuff up to them as – this is just good policy, it’s not just good for the people and the budget, it’s good for you, it’s the right way to go. And I think the leaders respond to that. When you come to them with a winner they absolutely respond. And they have in Vermont. They have given us plenty of space to take this policy and run with it as it’s evolved, which it has. So I think we’ve found very receptive ears and frankly, I think that any governor or any legislature, when they fully understand what we’re able to do and what we’re doing, would embrace it.

Forrester: Commissioner, how do you – so take us down into that a little bit more -how do you make the case for change? How do you structure your briefs? How do you communicate in those rooms? And what is some advice for other would-be change agents in governments attempting to think the way that you do?

Flood: Well, first of all you got to know what you’re talking about. There’s no sense flapping your jaw about an idea if you don’t have something to back it up. So we actually spend a fair amount of time pulling the data together. And that’s really important so you can make a cogent argument. You have to be able to make it quickly. You know, these are not people that want to spend three hours being lectured to about a particular issue. They want you to cut to the chase, explain what the goal is, how you’re going to get there, what are the obstacles, what are the challenges, what are the potential down-sides and what’s it going to cost. If you can do all those four things in a pithy way you can get not only their attention but their approval.

So, you know, sometimes obviously, I don’t want to state the obvious here, but politics comes into play as well. And you just have to be mindful that you can’t be naïve about what it’s going to take to get from “A” to “B” that there are vested interests no matter what issue you’re talking about. There are vested interests within government, outside of government and how are you going to deal with those. And you have to be prepared to make compromises along the way as long as you’re not compromising the overall direction or the overall success. That’s just the reality in getting things done. But I think at the heart of it the key is keep your message simple and straightforward so that they can repeat it, they can internalize it, and they can repeat it and then if they get it very quickly then it makes sense very quickly and have the data to back it up. And you have to have some credibility, you know, you can’t just walk in and change the world. You have to build that credibility and in this particular case we were able to do that. So our change has been incremental. We have not seen, you know, drastic change in the long-term care system. We made certain changes and then we made other changes. And what you saw in the Wall Street Journal article was really just a next major step in a direction. And we’re not done yet. There’s other changes to come and we’re actually engaged in the very process now that you and I are talking about which is convincing my bosses that there is another whole frontier out there in terms of taking care of elders and people with disabilities that we’re prepping for right now.

We’re getting the data. We’re having a preliminary conversation with all the right people. Another piece is you must bring in your natural allies – it probably sounds trite or obvious, but you have to make alliances with the people that think the same way, that have the same values. In our case of long-term care, we’ve created an alliance between people with disabilities and elders who don’t always see eye-to-eye and the providers of care. So you bring in your allies and you build that coalition and that’s really important, as well.

Forrester: Now before I leave that topic, is the preferred media that you use – I feel like we’re all a victim of it at some point – is it PowerPoint? And can you talk a little bit about that? Are you a visual person? Or are you someone who moves a room more by the way that you that you speak?

Flood: Well now, somebody else should probably answer that question besides me, but I try to use all different approaches because people learn differently. That’s just a fact. And so some people you have to have visuals for. When you’re in these kind of discussions, your personality or your personal approach has a lot to do with swaying people. In my particular case, and I think this is true for anybody trying to take on a change like this, you have to believe in it. It can’t be just a career move; it can’t be just a dry topic. I believe here deeply in what we’re doing. I still carry around with me the stories of the bases from 20 years of doing this work; from 25 years ago when I was a nurse. Those stories still motivate me and I think I use that and it comes out in my presentations. It’s not just the bureaucratic change. This is something that’s important to people and we actually care about it. So, you know, yeah, I use PowerPoint and I’ve gotten pretty good at it, but that’s an important part of the information. But mostly important I think is having someone at the front of this discussion who believes very deeply in what this work is and what a difference it makes for people.

Forrester: And let’s switch the conversation a little bit then, Commissioner. I’m deeply familiar with your story based on articles because your personal brand is growing around the country. Can you frame for our readers what’s at stake and what the major reform is that the country is watching now and the experiment that Vermont has put in place with elderly care?

Flood: Ok, there’s really two parts to the answer. The first part is what’s at stake. In different terms, first of all the current model of providing services to people is simply unsustainable. Just take out your calculator and do the math. We cannot put everyone in nursing homes ten years from now, we’ll never be able to afford it. So that’s problem number one which everybody recognizes. But more importantly, actually, is that it’s simply not what people wanted. They really didn’t want it 30 years ago, they didn’t want it twenty years ago, they didn’t want it a decade ago and they don’t want it today. People prefer to stay at home and to be cared for by their families if at all possible or by people they know if at all possible, to be surrounded by their personal things and to live in their communities; and for the disabled people, not only to be cared for but maybe have the opportunity to work and to participate in independent living.

So, you’ve got two imperatives: you’ve got an imperative around money and you’ve got an imperative around what our society’s evolving to and what people want. So, the big change that we created is that we needed to find a way around what’s called the institutional bias where Medicaid will pay for institutional care but it limits what it will pay for in terms of home-based care. Our goal was to equalize the treatment of services under Medicaid. In other words, equalize either access to nursing home care if that’s what somebody wants (there are still people who need that), but equally giving people the same opportunity and the same access to stay at home. And our theory, of course, about that is actually it is cheaper on average. Not everybody, but on average it is cheaper to have someone in their own home because you’re not paying for the housing and you’re not paying for the food. So it’s cheaper and you can serve more people with the same amount of money. So we had to break down this institutional bias, which really blocked us into putting more of our money into nursing healthcare. And that’s what our waiver from the federal government really does. There’s some complex, you know, regulations and terminology you have to get into but basically we found a way, we think, to create equal entitlement to either nursing home care or home-based care and still manage it within an appropriation.

That’s what the federal government really gives authority to do, because no state today is going to create a brand new open-ended entitlement that they can’t control. Medicaid is already too much trouble. So what we said to the federal government is that we want to create equal opportunity but we want to be able to close the doors at some point to put people on a waiting list, basically, if we have to, if we don’t have enough money. And they said we could do that. That was not permissible under the old system. So what’s happened as a result of what we’ve done here is over the past year, in our first year we’ve served twice as many people at home-based or alternative settings than we ever could have under our old system where the home care was limited. We’ve seen reduction in the use of nursing homes and we’ve come in under budget. Now we still do have waiting lists, we have a small waiting list, but we had 250 people on that waiting list a year ago, we have 60 people on the waiting list today. So we clearly accomplished mostly everything that we set out to accomplish.

Forrester: And Commissioner, do you think that this model and, working in the waiver context, is that scalable to other states that have, to the earlier part of our conversation, just massive more amounts of people and a different distribution of elderly?

Flood: Yeah, absolutely. There’s no reason that the concept can’t be used in any state. I recognize the challenges of a state like California or New York, and it may take them longer. That’s what I see, it’s not a matter of whether they can do it, it’s a question of how long it takes to get all the systems in place to serve everybody. But those states are already doing some of this work. If they just took our approach, it could speed things up.

Forrester: You alluded earlier in the conversation to additional innovations to come. Can you comment on some of the new things we should expect from Vermont?

Flood: Yes. I think it ranges from just new service options to systemic change. Let me give you two examples. One thing we have not done here before is try to find ways to provide 24-hour care to somebody. You know, we provide a lot of services in our waiver, it’s a very generous waiver, but we don’t provide somebody to stand by your bedside 24 hours a day; that would be too expensive. But what we’re looking at now is a way to provide a sort of a foster care arrangement where certain people – older people or people with disabilities – can actually be taken into a home along the lines of a foster care arrangement, and that would be more cost-effective than trying to pay an hourly rate. So we’re looking at ways to provide that 24-hour service because those are the people that still need to go to nursing homes. That is the people that we can’t find any way to sort of supervise 24-hours a day.

Forrester: In that foster care model can you give me an example? Are you saying that if I was a willing participant up there, I’m a forty-something living up there in Vermont and there is this need in the state to take care of people that I could literally almost adopt someone to bring into my home?

Flood: Well adopt is the wrong word because that has all these legal connotations. But we would have a contract with you and someone could come into your home and you would basically be responsible then for them for 24-hours a day, however, you would get support services to help you do that so that during the day the person might go to some kind of a respite service or an adult aid program so that you could work or that you could get a break. Or the person might get some of their personal care from a nursing agency. You wouldn’t have to do everything yourself and yet the person would be safe in your home at night, for example. We would pay some kind of contractual rate of, whatever, $25,000, $30,000, $35,000 a year to take care of that person.

Forrester: At a business case level, this just has to make sense compared to the exorbitant cost, to your point, of putting someone in elderly care 24-hours a day. The business case seems obvious.

Flood: Yes, it’s absolutely obvious, we can’t afford to pay an hourly rate, because we pay good rates. We couldn’t afford to pay that for 24-hours a day so we come up with this kind of contractual approach. And I must say we’ve been doing this with people with developmental disabilities for over a decade. So we know it works. If it can work for people with developmental disabilities there’s no reason it can’t work for some elderly.

We’re also doing something else that’s called in the national lingo “catch and counseling,” it’s really quite a misnomer. But the idea is you give the consumers a spending plan. Instead of saying to them you’re going to get x hours of this and x hours of this and blah, blah, blah, you say to them, you can manage your own services. We would have spent, let’s pick a number, we would have spent $20,000 a year on you in the old system so we will give you $20,000 of spending authority minus some administrative costs which you won’t have now, and you can manage your own services. You can hire your own caregivers, you can save some of your money and buy some equipment if that’s what you need, you can pay your caregivers more than we would pay them. We would give the flexibility to the consumer to manage their own services. So that’s also just starting but evolving, and I’m a firm believer in it.

But I want to mention quickly the systemic changes, because the next generation or the next frontier here, I think, is what we call integrating the long-term care services with two primary care services. There is so much lack of coordination and sometimes duplication and actually a cost shifting in working against each other between the Medicare program and the Medicaid program, between the incentives to get people into hospitals versus caring for them at home sometimes or doing outpatient stuff. That all needs to be redesigned from a consumer’s point of view, what’s good for the consumers, and I believe that if you do integrate all those services you’ll not only give better care to people you’ll save money in the healthcare system. And it’s already been shown in some projects, I don’t know if you’re at all familiar with something called PACE, which is the program for all-inclusive care for the elderly. It’s been around for a long time. And that’s what we wanted to do systemically, we don’t want to have just one program or two, we want to take the same approach to all this care, integrate the long term care and the primary care and we think we’ll save money.

Forrester: Commissioner, we’re winding down, I want to be respectful of your time. This is kind of a personal question, how has your life changed since you’ve been on the cover of the Wall Street Journal? And I can’t imagine that when you Google Patrick Flood there’s a lot more that comes to light now. You’ve been quietly in the background and now you’re kind of forefront, how is that feeling?

Flood: It feels fine; you just get a lot more phone calls right now. I think that will calm down in a while, it’s already calming down. Other than that, you know, just my family teasing me about the picture in the Wall Street Journal.

Forrester: Commissioner, what’s next for you?

Flood: I am a political appointee, and it’s always been interesting to be in that role because you can be out of a job in a minute. But I think I’m committed to this work for a while. I think that, as I said, there’s a new frontier here, there’s a lot of work yet to be done and I can see it, I can taste it. Its right out there and I think we can achieve some other great things in the next two or three years so for the foreseeable future I’d like to just stay in this work. I’ve got a great, great team of people working here and I think we can achieve great things and continue to show other parts of the country that this stuff is doable.

Forrester: Well, Commissioner, we will be watching you and I want to thank you on behalf of Sapient Corporation and governmentchangeagents.com for this fantastic conversation.

Flood: Well, thank you, it’s my pleasure.

End

The Change Agents, Glasgow, Scotland: Skill, Confidence, Motivation

For today’s post, GCA.com has decided to feature a guest letter. Robert Livingston, Founder and Managing Agent of The Change Agents writes from Glasgow, Scotland. He originally approached us to present his bi-weekly newsletter, saying, “my approach is to challenge, educate, and motivate thinking about change, the leadership required to be an effective agent of change within the workplace, personally, or within the community as a whole.” After corresponding with Mr. Livingston, the editors at Government Change Agents agree that Mr. Livingston offers some valuable insight on the concept of Change Agents – and a unique international perspective. Here is his letter, let us know what you think. We look forward to featuring more guests in the future.

——————————————————————————————————

Greetings from Scotland!

Here in Glasgow, on the other side of the Atlantic, The Change Agents work with a diverse range of managers and leaders. Our stated client aim is simply, “To impart the skills and confidence you require to manage change.“

Our straightforward aim is inspired through observation: no matter who you are, if you want successful change to occur in your life, work, or community; you require the skills, confidence and motivation to make it happen. This truth has been evidenced in the corporate world, in higher and further education, and in the charity and social enterprise economy here in Scotland. Further, the attributes of skill, confidence, and motivation appear to be so fundamental to change I am convinced you can measure your success or otherwise via this formula: skill + confidence + motivation = change. It’s a bit like baking a cake – you require the correct skills and ingredients for a successful outcome!

Funny enough, The Change Agents’ tagline is “to create brighter futures” i.e. successful outcomes. However, here and throughout Europe, few people use the term “change agent.” Instead, government and business leaders refer to their need for people they can depend on, people who regularly come up with creative ideas, and people who can rise to a challenge and win. In essence, they unwittingly describe the classical attributes of a “change agent.” Naturally, these people are who The Change Agents vigorously support through leadership development, management mentoring, and via training and facilitation workshops – such as SPEAK UP!

In providing this support our objective is to inspire individual men and women within organisations to take control, develop personal leadership, hone public speaking and influencing skills, and to encourage their colleagues to do the same. In this way, a critical mass of change agents can be formed. Their collective mindset is positive and they become an unstoppable force for change within the workplace. This concept is simple and effective- a winning hearts and minds strategy, and all it takes is skill, confidence, and motivation.

In recognition of this, The Change Agents distribute a fortnightly e-Motivate e-letter entitled “Themes for Change.” Its purpose is twofold: to educate the growing number of individuals and organisations who appreciate the power of change, and to provide motivating, challenging and thought provoking script to support them through change itself. If you think you or your organisation would benefit from this, visit our website www.thechangeagents.co.uk. In the interim, keep up the good work, keep striving for change!

Bobby Livingston.
Founder & Managing Agent
THE CHANGE AGENTS – creating brighter futures!

On Death and Dying

Previous posts dealing with the relationship between the public and private sectors have focused more on what government leaders can learn from successful private industry strategies than on learning from private sector failures.  Leaders in each sector face unique challenges, but there are a few fundamental pitfalls that can hinder a leader in any arena.

In their study, “On Death and Dying: The Corporate Leadership Capacity of CEOs,” John Slocum, Cass Ragan, and Albert Casey explore character traits and factors that can lead to the “corporate executive ‘death’”.   .  These are leaders of some of the world’s most recognizeable companies; whose careers were previously marked only by success.  “On Death and Dying” identifies self-sabotaging habits common to leaders who either leave or are prematurely forced out of their organizations.  They pinpoint following three critical failures, leading to untimely CEO departure, and ultimately damage to the entire organization:

• [failing leaders] often have been members of their organizations for a long period of time and…cannot dismiss or reassign poorly performing managers
• [failing leaders make] strategic decisions that cost their company its competitive advantage in the industry. They either failed to execute a strategic decision or solved the wrong problem well
• [failing leaders avoid] the financial realities facing their firm

The first two failures are clearly apparent in the government sector, and although government leaders rarely interact directly with financial results, any refusal to aknowledge the truth can afflict any leader.

 As it turns out, Slocum argues, the last, self-sabotaging, habit is key to understanding the behavior of those facing career-threatening crises.  In order to understand this behavior, Slocum, Ragan, and Casey applied to each case the model of the 5 emotional stages of a terminally ill patient: denial, anger, bargaining, depression, and acceptance. Failing leaders, they discovered, go through the same progression of stages, and whether or not the leader and the organization recover depends largely on the ability of the leader to reach the stage of acceptance.   Those who were caused serious organizational disruption and unable bounce back from their failures were those who got stuck in the denial stage.

By attributing their failures to everything from internal conspiracies to uncontrollable external forces, these “unproductively narcissistic” leaders left their organization having never accepted the true cause of their problems, and therefore never taking corrective actions.   This type of leader often creates an environment in which subordinates feel unable to deliver bad news for fear of becoming the scapegoat.  In the precarious world of government leadership, where a highly-publicized failure might mark the end of a career, it is all too easy to create an atmosphere of willful ignorance.

This paper was originally published in Organizational Dynamics and is available online (unfortunately access requires a paid subscription). More information is available on John Slocum at his website.

Quiet Leaders – Can Change Agents get anything done without Yelling?

On the change agent journey, many have asked me if these exceptional people are always the alpha, extroverted,  inspirational leader.  The answer is no.  I have seen many change agents with enough patience to quietly wait for their moment to lead. These people are a type of change agent I term a “dogged conceptualizer.” A new book explores the idea of quiet leaders, and this HBR article caught my attention.  I really liked this exchange from the Q&A with the author Joseph Badaracco:

Q: When most people think of leaders they think of real brash types, even rebels. In business, for example, Jack Welch springs to mind as a well-known leader. The idea of a quiet leader seems almost the flip side of that.

A: It is the flip side of a standard or stereotypical view of a leader who speaks the truth or says what has to be done, who inspires others to do it in a critical moment. But I’m skeptical that in the countless meetings Jack Welch spent his career going to, in each one of these meetings it was the Jack Welch Show, and that he heard what everybody had to say and then announced the right thing and inspired everybody to do it. You have the famous example of Rosa Parks, saying, “I’m not sitting in the back of the bus.” Well, while that was a remarkable act of courage on her part, and in some degree was kind of a spontaneous event, she’d just had enough of this kind of treatment from one particular bus driver. She’d even stopped riding on his bus and got on by accident. She’d been to a number of civil rights training programs. After she was arrested, the people in the civil rights movement sat down and asked themselves, “Is this the right person, is this the right time, is this the right case to challenge segregated busing?” So there’s a lot of preparatory work and a lot of careful work afterwards. Quiet leadership is not really the flip side. If you look behind lots of great heroic leaders, you find them doing lots of quiet, patient work themselves.

Architecting for Change Agents

I came across a great article this week about a book instructing architects how to designing spaces that foster collaboration. I must say the article made me think about the spaces in which we operate.  The design of a room and its tools set a larger context for how people collaborate and build relationships; ultimitely enabling change agents to be successful in getting to their vision.   Some of the designs are simply inspirational.

Here is a brief description from the article:

“NBBJ, a global architecture, planning and design firm, collaborated with Toronto’s Bruce Mau Design Inc. to produce a finely illustrated book examining a series of the firm’s projects produced over the past decade. Released in September, NBBJ intends this book to be the first in a series of publications to describe, through a case-study methodology, the range of client relationships dealing with issues such as environmental audits and stakeholder objectives. The various projects apply the firm’s ‘change tools’ an array of key design strategies that relate to vision, collaboration, communication and delivery. Each tool targets a specific goal and acts as a framework customized for each client.”

The article also offers a few interesting examples of the firms work. Take a look at a few by clicking here.