NWX-HHS-AOA-1

Moderator: Lauren Solkowski

06-19-13/1:00 pm CT

Confirmation # 1375441

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NWX-HHS-AOA-1

Moderator: Lauren Solkowski

June 19, 2013

1:00 pm CT

Coordinator: Thank you for standing by. All lines in today’s call are in a listen-only mode 

until the question-and-answer session. At that time for an open line you can 

press star 1. Today’s call is being recorded. If you have any objections, you 

may disconnect at this time. And I’d now like to introduce Lauren Solkowski, 

Program Analyst. You may begin.

Lauren Solkowski): Thank you (Michelle). And thank you to everyone for joining us for 

today’s webinar on Personal Stories Moving into a Business Market 

Approach. As mentioned in the calendar appointment, the purpose of today’s 

webinar is to hear personal stories that other community-based organizations 

have encountered in developing their business acumen and working with 

healthcare providers and plans.

Before we get started and into the bulk of our webinar, there are a few 

housekeeping announcements that I’d like to go through really quickly. If you 

have not done also already, please use the link included in the calendar 

appointment to get on the WebEx so that you can not only follow along with 

the slides as we go through them but also ask your questions when you have 

them through chat.
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If you do not have access to the link we emailed you, you can also go to 

www.webex.com and click the Attend a Meeting button at the top of the page 

and then enter the meeting number which is 666685392. That was 666685392.

If you have any problems with getting into WebEx, please call WebEx 

technical support at 1-866-569-3239. That’s 1-866-569-3239.

As (Michelle) mentioned all participants are in listen-only mode. However we 

welcome your questions throughout the course of the webinar. There are two 

ways that you can ask your questions. The first being through the web using 

the chat function in WebEx. You can enter your questions and we’ll sort 

through them and answer them as best we can and take breaks for questions -

small breaks between each person presenting.

In addition after the teams wrap up we will offer another chance for you to ask 

your questions through the audio line. When that time comes (Michelle) will 

give you instructions as to how to queue up to ask your questions. If there are 

any questions that we don’t get to answer during the course of the webinar, we 

will follow up to be sure that we get them answered. If you think of any 

questions after the webinar, please email them to me at 

Lauren.Solkowski@acl.hhs.gov.

As (Michelle) mentioned we are recording this webinar. I will provide 

information on accessing the recording after the webinar has concluded. So I 

think with that I’d like to get started.

Before we hear from our two community-based organizations, I’d like to 

introduce June Simmons who is the CEO and President of the Partners in Care 

Foundation that is here to make an announcement on behalf of the John A. 

Hartford Foundation. June are you there?
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Moderator: Lauren Solkowski

06-19-13/1:00 pm CT

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Coordinator: June check your mute button please. Just one moment and I’ll pull her line to 

check.

Lauren Solkowski: Thank you.

Coordinator: June Simmons is joined.

Lauren Solkowski: (Hi)...

((Crosstalk))

June Simmons: I’m very sorry. I was on the line, it cut me off, and then when you introduced 

me I was on the line but you couldn’t hear me. So hopefully I’ll be worth 

hearing now that I’m here.

Lauren Solkowski: Right. Thank you, June.

June Simmons: Good morning. Just briefly I bring greetings from the leadership of the John 

A. Hartford Foundation whom I know you all appreciate, have been fantastic 

investors in advancing aging and health and bringing support to the Aging 

Services Network and healthcare for aging.

And they are beginning some new funding investments and so I have the 

privilege of announcing a new grant that they have just approved that their 

board called Improving the Health of Older Adults Using Integrated Networks 

for Medical Care and Social Services.

They’re running that grant through Partners in Care Foundation here in Los

Angeles and we are working closely with a (sub granted) distinguished site 

you’ll be hearing more from later, Elder Services of the Merrimack Valley 
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and the grant also is designed to work in close partnership with ACL on this 

learning collaborative.

The grant in brief is looking at prototyping how we link Coleman Community 

Services and medicine through building business structures and clinical 

partnerships so we are prototyping.

In Los Angeles we’re prototyping around three service lines evidence-based

self-management short-term in home care coordination and support and then 

longer term services and supports at home. So it’s three different kinds of 

network models and Elder Services of the Merrimack has strength in several 

of those areas and it’s prototyping by building a statewide network for 

evidence-based self-management workshops and its contracting capability.

And we also are working with the evidence-based leadership council that 

brings many of those management programs to all of us across the country 

and that group is working to integrate their efforts and streamline accessing 

through a shared portal. It’s a three-year program. And so I don’t know if 

there’s more you’d like to know about it, but I don’t want to use too much 

time except to say it’s a major investment by the John A. Hartford 

Foundation.

And then there’s sub funding to Merrimack and the (unintelligible) 

Foundation is matching that so it’s very exciting and a budget is a little bit of 

money that’s been advancing the ACL collaborative that we’re on this 

morning.

Lauren Solkowski: Thank you June. And then also if you could mention that as you just said 

in advancing our collaborative for ACL that the plan to also host the in person 

meeting.
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June Simmons: That’s what our funding is from Hartford that was placed through the Partners 

project will be used for a variety of efforts and one is to see if we can create 

support for an in person gathering of the learning collaborative. And also if 

this learning collaborative should have a shorter rather than a longer life, we 

are - at Partners will continue to help with supporting it over the three-year 

period as well so that national learning and dissemination of the local 

prototyping efforts made this a very natural investment by Hartford to support 

the ACL initiative with some support for in person gatherings.

Lauren Solkowski: Great. Thank you so much June. And now I’d like to turn it to Roseanne 

Di Stefano. She is the Executive Director of the Elder Services of the 

Merrimack Valley.

Roseanne Di Stefano: Hi folks and good afternoon. As opposed to June, we’re out in the 

East Coast. So we’re in the afternoon time. All right. So I’m going to - I want 

to try to go through this quickly. I know I’m talking to a bunch of our really 

esteemed colleagues who have already pursued some of this work and see if I 

can enlighten you at all in terms of how we started.

I’ll begin with, you know, creating relationships with the healthcare 

organizations. And what I would say here is that the best place to start

obviously is where you have any kind of relationship with either a physician 

group or any kind of healthcare provider. Use your existing relations to open 

the door and begin to talk to them about what they’re pursuing. And I’m going 

to talk about two examples and one is an ACO and one is a non-ACO. One 

has been a success and one I would say is - I won’t say a failure, but we 

haven’t been successful yet.
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In the case of the non-ACO, we began talking to them a few years ago about 

the concept of medical homes as it was something that they were interested in.

And it led to us going to a conference together down in Washington and that 

really helped to get to know them even better.

The conference was on medical homes and we were listening with them about 

what it will take for them to change their very large physician practice into a 

medical home. So I built some really nice bonds there although as I say this is 

the example that has not been successful yet.

At the same time we really started working with another physician group 

that’s located in (unintelligible) that had pursued the pioneer ACO funding.

And in this case the timing - I think the timing was right. We had had previous 

relationships with them when they had pursued the managed care contracts.

So some I would say eight to ten years ago we actually had a contract with 

them early on that was not continued, but not because of us but really largely 

because the pilot that they were working under in Massachusetts was called a 

social healthcare managed care organization and that didn’t continue. But the 

point is that we had relationships.

So what I want to say here is that obviously you can’t start cold. So you start 

where you have some connection and you really try to do your homework in 

terms of what kind of organization are there - are they and what are their 

incentives. Are they pursuing ACO status, are they pursuing medical homes, 

are they a hospital that you work with already. So think about all of that and 

then you have to think about okay what do you bring to them.

And sometimes the most obvious things are confusing to the medical 

community in that what is an Area Agency on Aging anyway. And we had to 
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really distinguish ourselves from a home health agency. There is a lot of 

confusion for whatever reason I think with the medical providers as 

community base is all one thing and it’s there out and this and that when the 

nurse goes out and takes care of things.

So we had - let me very clear in terms of what we offer and how that’s very 

different from a home health agency and in particular emphasize the fact that 

we have a neutrality. We don’t represent any particular service provider and in 

fact we’re not a service provider.

We can help them in assessing risk, identifying their highest risk clients, and 

why - what the home looks like by actually dong a home visit, doing a home 

safety analysis, talking to the elder about, you know, where they’re having 

difficulty in complying with the medical tier plans we can get much deeper 

into a conversation because as you know oftentimes even if an VNA is going 

in they may not address issues such as income, being able to afford 

medications, the housing situation, safety, and others. So being able to 

differentiate yourself and be clear about what you can offer.

The other thing I would say is you obviously have to stop talking about return 

on investment with them and by that I mean - well in the early days, I wasn’t 

sure what it meant to be honest with you, but I knew that we could have an 

effect on how people utilize their physician’s visit and how they could better

utilize a physician’s practice. How we could keep them out of emergency 

rooms and hospitals by looking at for example some of the evidence-based 

self-management programs. So all of that was part of our pitch to them on the 

return on investment.

Also I would also say that in order to getting - being ready, you have to look 

at your program costs and if you were to provide care coordination there’s a 
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lot involved in terms of what - it’s not just the salary and fringe benefits of a 

particular worker. Obviously you have to really bring in all those services and 

programs that you offer that you think they may take advantage of.

What we did with the first example that I talked about is that we try to 

anticipate their need to do the budget on a PMPM - a per member per month 

basis and they just looked at us kind of crazy and said yes, but what’s the cost.

So we anticipated that that’s how they needed the budget and it turns out that 

no a monthly cost was fine and they understood that it would be a very 

inclusive cost. Again not just looking at the salary and fringe of a particular 

care manager, but rather all the services and programs that we would bring to 

bear.

Finally I would say on this piece is that for us we’ve been successful because 

we’ve been willing to try it on a demonstration basis or on a pilot basis at no 

cost. That means there’s no contract to sign. Yes, there’s a memorandum of 

agreement and you have to respect confidentiality and such, but by not 

entering into a contractual agreement at the get go. You really - you’re saying 

look let us prove ourselves to you, let us see what this cost, let’s see how you 

can use it, and then let’s - we will sit down and look at what the cost of 

delivering this long-term would be.

I would caution people to not make the mistake that we did which is, you 

know, speak about an end date. Is it a six-month pilot? Is it a year pilot? We 

were willing to do a year pilot, but it took a year and a half even to get to the 

point where we realized we had to actually stop the pilot to get their attention 

so that we could begin to negotiate a contract. That’s a long story for perhaps 

another webinar. But I would say that make your pilots time limited, but give 

yourselves enough time to demonstrate your effectiveness.
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So in terms of barriers - by the way I’m just, you know, just move the slides 

as you want - in terms of barriers as I say some physician groups are not going 

to be ready. If they’re not at risk and they don’t plan to be at risk in the near 

future, you might not catch their ear.

The idea of becoming a medical home is appealing I think to a lot of physician

groups, but then they realize what that means and that it might cost them some 

money and again some of them are simply not ready. They may have some 

payers that are incentivizing them based on how they address high-risk 

patients, but that may not be enough for them to really think more broadly 

about how they can use a community-based organization.

Again I think the - when you pursue - when you get to the point of actually 

developing that pilot or if you’re lucky a contractual relationship from the get 

go, you know, be clear about what you’re going to be able to define as your 

outcomes. Sometimes there’s an expectation that, you know, we can do a lot 

more than what we can actually do and some things are difficult to define.

For example oftentimes as you empower a consumer to use healthcare more 

effectively, they may actually use the physician more in the beginning because 

they have more questions, they are more engaged. So that it may not simply 

be, you know, a reduction in costs in the office visit. In the beginning it may 

actually be a more comprehensive visit, but long-term what we hope to do is 

reduced costs.

I would say that one of the other things is you need buy in from all levels of 

the practice. This is easier said than done. We had some excellent buy in with 

the physician group that has not yet been successful, but we had buy in with a 

very small group of physicians. They understood that they were part of the 

pilot and part of the demo, but it never spread. So because it didn’t spread and 
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because it was so narrow, I think that made it hard for us to prove our value 

down the road.

Okay let’s see. I’m going to go culture change. The trick is a lot of work I 

think administratively as well as your agency as a whole to be ready for the 

contractual work with private payers. It’s very different than like most of our 

funding for years had been from the state and federal government through, 

you know, through legislature and this is very, very different. So obviously I 

think again I’m speaking to people that understand and know the difference.

But understand that your customer now is not just your elder and making sure 

that the elder or the older adult gets better care, but it’s also the payer and 

tuning into what the payer needs and wants.

In looking at your costs, it’s really for many of us who grew up in the early 

days of funding from the Old Americans Act we really didn’t have a sense of 

individual cost for different - for individual services. And I think that takes 

some time and energy to really begin to look at the labor hours that are 

involved. For example with one person receiving money management 

counseling or one person from a (shine) counselor which is on health 

insurance, but also how long does it take to do an assessment. What level of 

person do you need and how quickly can they do the documentation.

I would say that there’s a lot of I guess they call it the business acumen 

because it’s really a way of looking at your - how you do the work that you do 

differently I think through a different lens. The work doesn’t change, but 

you’re looking at it I think differently.

I think you’re aligning your goals with theirs, but for this contract not for 

everything that you do. Built in this contract you have to identify that your 

goals are their goals and it’s certainly reducing costs, but also improving 
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quality and I would say patient satisfaction. While patient satisfaction doesn’t 

reduce costs, it does build loyalty and that is another thing that I think helped 

tier systems (and) very, very concerned with about whether they’re an ACO or 

a physician group or whatever, they want the patients that are enrollees to be 

loyal to them.

I would say also the other culture change is really looking in house as to how 

your care managers used to working. It’s important that they’re used to 

working as part of a team and to be a part of a team not only of other 

colleagues such as themselves, but an interdisciplinary team to understand the 

concept of sharing a case.

That I think for us it was one of the bigger changes of case managers feeling 

they own, this is my case load and I’m responsible for these 100 people to a 

point where no there are going to be a lot of people that are concerned for 

those 100 people. And you might be the lead tier manager trying to coordinate 

different members, but you’re going to have a nurse, you’re going to - and in 

this case you’re going to have outside folks that absolutely have to feel that 

they’re part of your team and you’re part of their team.

I think where we’ve been successful, the physician practice has really 

embraced us and that we are part of a regular rotation or rounds, whatever 

they call it, so that we’re reviewing with them the high-risk patients or 

enrollees that they have and brainstorming with them about what we need to 

do. So that’s where it works best.

So the big picture, changes for success. I would say that again that, you know, 

thinking about interdisciplinary approach, think about a pilot. Be willing to 

move quickly to make changes in the pilot because oftentimes they don’t 

know what to expect and you’re not sure exactly what to expect both in the 
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amount of time each referral will take. But also to some extent where do you 

start.

I mean in some cases you might have to define a maximum amount of hours 

that you would spend per case just because there’s going to be very 

challenging cases that may refer to you and you may want then to refer out of 

this pilot to other systems and other community programs that you know exist.

I would also say in terms of big picture that it’s important - it’s always been 

important to us to share the vision with all our staff not just the staff that are 

working on a particular demo. It’s important to me that everybody 

understands what we’re doing and why we’re doing it and what’s down the 

road.

Why the bridge between community-based organizations and the medical 

community is so important. And I would say that same talk is also something 

that I emphasize with our board members. It’s important as every CEO knows 

not to get too far out in front of your board and make sure that they understand 

where you’re going, why you’re going down that road because it’s so 

different. And I think there’s always a little bit of concern is this taking us 

away from our mission. And when you can explain how this is absolutely

enhances your ability to be successful in your mission because you’re 

impacting the healthcare of older adults, I think you get the buy in that you 

need.

And then finally I would also that just being excited about these opportunities 

is contagious and it’s something that I think it’s good to share and for 

everybody to feel part of it. Okay.
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So the last picture - the last slide is really something that we’ve used in 

several different presentations to look at kind of overlaying the Wagner model 

for chronic disease self-management or chronic care model, I’m sorry.

Looking at the Wagner model and then using the name of organizations.

In this case you’ll see we put Elder Services. Yes, firmly rooted where the 

community programs are, but then looking at the care transitions work that 

we’re doing with the CMS and the medical care coordination as a bridge to 

the healthcare systems as well as and you’ll see the Healthy Living Center of 

Excellence which is our infrastructure. Our center to really expand and build 

upon the capacity across the state of evidence-based programs and wellness 

programs such as the (Prime) Disease Self-Management model.

These are some of the things that we bring to the healthcare systems because 

oftentimes opens doors. They are very - might be very interested in these 

wellness programs before you even can talk about care coordination. And 

other times they’ll talk about care coordination for us and then you bring in 

the wellness programs after that. But absolutely they are part of the bridge. So 

I’ll stop there. I think my time (unintelligible), but (unintelligible).

Lauren Solkowski: Great. Thank you so much Roseanne. I’m currently not showing any 

questions in chat so I think with the interest of time we’ll go ahead and move 

on with our next presenter and then we’ll do questions at the end. So up next 

we have Sharon Fusco. She is the Director of Business Results and Innovation 

at the Council on Aging of Southwestern Ohio. Sharon?

Sharon Fusco: Good afternoon everybody. Thanks for having me and it’s always tough to 

follow a really good act. So I hope I can do this some justice. So I think 

you’re bringing up my presentation. I’m not seeing it up on the screen.
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Lauren Solkowski: Yes, I’m pulling it up right now.

Sharon Fusco: Okay. All right. So, you know, obviously we were asked to talk to you on 

what are the big picture changes and sort of how did we get there and talk 

some about our relationships that we built with the healthcare system and so 

forth. So I will try to do that by really telling you kind of our story from COAs 

perspectives sort of what happened to us and to do that I’m going to have to 

take a time machine back to about 2006, but I want to start by just giving you 

sort of a sense of who we are. So if you want to advance a couple of slides 

that would be good.

The Council on Aging is - the next slide - yes, we’ve been around for about 41 

years. We were the, you know, very AAA. We’ve got a fairly large region.

Five counties in Southwest Ohio. And if you could advance to slide 5. Our 

core functions, you know, we administer tax levy funding, Medicaid waiver

funding. We do services like pre-admission review, care management, care 

coordination, care transitions. All of the other functions that go with being in 

Area Agency on Aging.

We are one of the largest non-profits in our area and have a pretty good 

network and about $100 million coming in annually that we are working with 

to serve our clients. And we serve I think on the next slide, you’ll see that we 

serve about 20,000 clients a year and you can see some of the statistics. So 

this is who we are in terms of an agency. But as I said our story really starts in 

2006 when we really started seeing some changes in our system. And if you 

go to slide number - I’m going to skip a couple of slides in the interest of time 

and you can’t see my son’s little picture but okay. Let’s - yes.

So what I want talk to you about is today is how did we move from sort of this 

scared Lucy picture to where we are today. And I wouldn’t say we’ve quite 
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achieved this free-wheeling picture of driving the road and life is easy, but we 

are certainly closer to that than we were when we began this quest.

So our current situation - next slide - is that it does feel a little bit like this 

picture from Lucy and we’re sort of scared to death, but we aren’t really 

standing still and waiting to see what happens. It’s more like trying to catch a 

bullet train and we feel like we’re just one step of what that bullet is. And that 

bullet really is how things are changing in the medical world really impacting 

us as COA. And we saw this bullet coming back in 2006. So if you’ll go to the 

next slide.

And in 2006 our organization is pretty much what I would describe sort of a 

sleeping giant. We have very much a family orientation. We thought we were 

number 1, but when you ask us what we were number 1 in we really couldn’t 

say. We really didn’t have the data to back that up. It was just something that 

we felt that we were.

And we were more about advocacy and heart in terms of how we viewed our 

role than we really were about budget and business operations. And this 

culture really permeated throughout our organization. So we were very much 

a business as usual. We’re just going to do what we’ve always done for the 

last 40 years. And when our new CEO came on board she took a look around 

and she saw some things that were pretty scary in our network. Next slide 

please.

The environment that we were in in 2006 was that we saw managed care 

taking its first run at our passport funding which is our Medicaid waiver 

funding and represents about half of our budget. And there was a huge, huge 

desire for us to also at the same time reduce our Medicaid spending so that 

was coming down from the state level. And there was an increased 
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competition just across the board not only in our industry, but in other 

industries for scarce resources.

We found that, you know, traditional fundraising, you look around and you 

see how these resources are tight. That, you know, we saw that happening. We 

saw more and more competitors in our market who wanted to do what we can 

do and believe that they could do it better and so forth. And this theme 

continued.

If I go back even just a couple of years those themes continue where the state 

is taking big budget cuts at our program and there was a lot of advocacy work 

that we had to do to maintain our funding. And the state at that time also 

became approved to do a dual (demonstration) looking at Medicare/Medicaid 

waiver services and turning our role over to managed care companies. And so

we looked at this environment and said this is pretty scary stuff. We’ve got to 

change and so those things were happening. Next slide please.

In a nutshell the bottom line for us was that we could see our funding streams 

changing. In the past it was all cost reimbursement. Every contract that we 

had whether it was for our tax levy - we had property tax levies to support 

Elder Services here and we managed those and those are all cost 

reimbursement. Likewise our Medicaid waiver, all cost reimbursement. And 

we knew that that was - we could see that that was changing.

Presently we are starting to see Fee-for-Service is here in our marketplace. We 

do have a care transition grant that we are paid Fee-for-Service. When duals 

project goes live, we will be paid on a per client basis to provide services and 

we will be paid by a managed care company. So that’s a big change for us.

And we know in the future that in order for us to survive we will be selling 

our services on a per unit basis.
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It is very likely that our payments may also include outcome and performance 

based incentives and that it will be to private payers, to managed care 

companies, to hospitals, to any wide variety of customers. So we know that 

that’s where we’re headed.

And so our biggest question - next slide please - is can we compete. We have 

that question in 2006 and we have it in 2011 and we have it today. And, you 

know, when you have a history of being a monopoly in terms of providing 

these services can we change fast enough. If we even had a, you know, I said 

we were a sleeping giant. We have that entitlement mindset that we of course 

will be the ones who will receive the funding and that we’re very quickly 

learning that no we have to compete for the privilege of providing the services 

that we provide.

And our competitors are changing where they used to be maybe other nonprofits or other home care providers or who thought that they could also do 

care management.

What we realized is that no it’s actually companies like managed care 

companies in the united healthcare world and the (Millenias) and so forth.

And so we need to be thinking about what are the right products. How should 

we be positioned in the marketplace? What relationships should we have. And 

it was great to hear Roseanne talk about, you know, thinking about those 

relationships and thinking about your products and services and so forth so we 

had those same questions.

And - next slide please - other things, you know, and the short story for us was 

that we had to prepare for the future and as part of that that we want to answer 
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- we needed to know that we could offer the highest quality services at a 

competitive price and maintain our market share and profit margin. Next slide.

So this is a question I often get from our staff which is profit margin. Really?

You’re really going to talk to me, I thought I joined a non-profit and we told 

them yes absolutely. If there’s no margin, there’s no mission. And so when we 

- moving forward we have to really understand how much our services cost 

and how much additional funding we have so that we can grow them and 

improve them.

And we had to dispel the myth that it’s illegal for a non-profit to make profits.

The bottom line and I try and make it really, really simple which is that nonprofits can earn revenue as long as you’re turning that back into your 

programs and services to provide better services to more clients, you’re on the 

right side of the law with regards to that.

And I always put my little disclaimer on here just to make the CFOs happy 

because there’s a lot more to it than that, but the bottom line for me is that.

And you’re hearing - off to the margin you’ll see, you know, social 

entrepreneurship is really a new name for that mentality that says non-profits 

are going to find non-traditional sources of revenue.

They’re going to move away from philanthropic to selling services, but there 

are non-profits that have been doing that for literally over 100 years. If you 

look at Goodwill and Girls Scouts and Boy Scouts and those are just examples

of ways that non-profits play in the for profit market and are successful at 

deriving from that unrestricted revenue which is always our best friend. Next 

slide.
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And there is more. There are other reasons to be thinking more about being 

competitive and thinking about market share and margin. The market that

we’re in is a hot market. I never knew that when I joined this market, but it 

was going to be the market to be in and there’s going to be a high demand for 

services but also a low supply of them. So there is some significant profit 

potential in that.

But as I indicated earlier there are many people who believe that they can do it 

better than we can do it. That they can do it at a lower cost and guess what?

They can. They can do it better and they can make money on it. And so what 

we had to help people realize - next slide - was the bottom line was we needed 

to start playing to win. And it meant for us that we could - if we can do that 

we can continue to provide a high level of services to our clients and be 

innovative and really deliver the most for the least amount of money. Next 

slide please.

So when I think about the big picture changes that we’ve made since 2006, 

they really focus in four different areas sort of a traditional organizational 

development model - structure, people, systems, culture. And I also included 

in there relationships because some of what you asked today that it is the 

external part, the part outside of our organization that we needed to focus on.

So there’s a real strategic emphasis from our strategic plan. If you go to the 

next slide.

We had a focus area that said to strengthen and position the organization and 

under that you can see what we put in for some of the strategies that we would 

employ to begin to align our strategic plan with what we needed to do to 

maintain competitiveness. And so - next slide, I’ll go kind of through those 

four areas with you and give you some real tactical things that we did from 

our organization.
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And the first one was to really think about our organizational structure. We 

did a massive restructuring about three years ago, four years ago and removed 

some extra layers if you will of supervision. We did a high focus on making

sure that the departments that we had were giving us some true value in the 

things that we would need.

And one area was the area that I currently manage was birthed out of this 

reorganization and it was the business results and innovation where we really 

focus on - we have teams focusing on analytics, and quality, and project 

management, business development. Really making sure that that’s a part of 

our structure.

We also put in a very innovative human resources team. Our human resources

director actually assisted the executive level and that’s really important for us 

because we need that person to be driving the culture and also be working 

making sure that we’re structuring the organization and always keeping that 

human element at the forefront of our strategic planning. So we put it at that 

executive level for that reason. And she has done just an awesome job of 

coming up with some innovative ways for us to be thinking.

We use self-directed teams. We have very few managers. We have team 

educators. We have very creative staffing structures. Additional duty and 

contract employees and things like that that allow us to keep our costs low.

And the quality of our service is high.

So the picture off to the left of the funky little bus is all about making sure that 

we are creating the right bus to carry the people that we need. And so that 

leads us right into having the right people on the bus. If you’ll turn to the next 

slide.
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And the issue here again it’s do you have the right people. Do they have the 

right knowledge, skills, and ability to do what you need them to do? And so 

we have a lot of focus on making sure (1) we have a fairly, you know, robust 

HR process whereby we make sure we bring the right people in. We screen 

them well. We develop them. We have certain organizational capabilities that 

we focus heavily on and make sure that people are in the right seats on the 

bus. It’s kind of a common theme that you hear over and over, but it certainly 

was a part of our strategy. Next slide please.

We also wanted to make sure that we have the right systems in place to 

maximize the resources that we had. And you heard Roseanne talk a little bit 

about making sure you understand your costs and I couldn’t agree more. And I 

will say that this understanding of costs really drove a huge cultural change 

for us and I’ll show you some of the ways that we did that in a minute.

But we needed to - (1) we need to fully understand how each position in our 

organization is paid for. We had to have conversations between program 

people and finance people to say this is the work that needs to be done. This is 

how it’s designed, but here’s all the things that go into making that work 

happen. Here’s all the people that go into it, here’s all the other resources that 

go into so we could really understand on a per unit basis what that cost looked 

like.

And that’s been actually work that has spread from our organization across 

our state because our whole AAA network in Ohio has been doing a lot of 

work understanding pricing and costs and that kind of thing and we trained 

everybody. We trained the directors, we trained our staff, everybody so that 

they understood it and that’s been a big factor in driving our culture change.
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We also have a pay performance system here and all of us have major work 

objectives and we are paid according to our achievement of those objectives.

And then there’s been a huge emphasis on technology and I would say this is 

the area that we continue to struggle with, but we have put in a fairly robust 

business intelligence system.

(SASS) Business Enterprise Guide does a lot of our analytics and makes them 

very accessible to our managers and to individual staff people so that they can 

see what their performance is. We can see what it looks like at a department

and an organizational level.

We also have, you know, a very robust electronic care management system to 

help us track information and then that information actually gets into our 

business intelligence system so that we can analyze the data that we can 

capture from that. So those things work in tandem with one another. And then

we do - we have other systems in place. Just as an example like (VPN) being 

able to work from home making ourselves very mobile, very agile as an 

organization has worked really well for us. Next slide please.

And I can’t emphasize enough and I think if I made any under estimation in 

terms of the change, one that needed to be made, and how difficult it would be 

would probably be the culture area. It’s the one area that keeps kind of 

sneaking up and catching me.

And so if I were to give any advice to anybody, it would be to focus on 

creating the culture. Don’t let the culture evolve on its own. Be intentional 

about how you go about creating the culture. And some of the things that 

worked really well for us were (1) we drove home the idea that you don’t 

make decisions if you don’t have the data to support it.
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So back in 2006 when we said we’re number 1, we didn’t know why. Today if 

we say we’re number 1, we got the data to prove it. And so we make decisions 

and we always are very intentional about going out and getting data. Right 

now our big focus is on positioning. How are we going to position our 

organization for the future and what products and services do we need to have.

We just invested a lot of money in market research to help us understand what 

it is our clients want from us and they want it packaged and what our 

customers need from us. So we made an intentional investment in that.

This focus on outcomes and getting it down to quality results and that kind of 

thing has been, you know, we had started with pay for performance and it 

continues and so even all of our chart reviews and things like that are more 

focused on the outcome and on the quality improvement we can get from that.

That’s all cultural stuff that we’re still in the throes of changing that culture, 

but it’s starting to happen.

And then the use of these cost models and price models I have alluded to 

before making sure that - that can actually drive a lot of your culture change.

If you go to the next slide I’ll give you a really good example of that. We 

developed this list - I give full credit to my accountant (Carl) who developed 

(Carl)’s grocery store model - back when we were trying to talk to staff about 

why it was important that they hit as many care transitions interventions as 

they could in a month. Why it was important that they hit their target of 

having a full case load of that.

And so we actually took our costs model - our price model and we flipped it 

over and said okay if you want a new - a telephone or a cell phone this is how 

many - this is what it cost and this is how many interventions it takes to 
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Moderator: Lauren Solkowski

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support that phone cell. And that was a huge - that was an eye opening day for 

our staff. It started to click with them that our world had changed.

And what we recognized as leadership was that the message it had to be 

presented in that kind of a way. It had to be made very, very tangible for our 

staff in order for them to start realizing that jeepers I play a really, you know, 

my volume matters. In the past we had brought in our best care manager into 

our care transitions program.

Our care transitions program was the first program that we had where we were 

paid on a Fee-for-Service basis and we thought using our best care managers 

would make it automatically successful. What we didn’t anticipate was this 

culture thing because they came in with this mindset of I need to spend time, I 

need to build lots of long-term relationships with my clients, and so forth.

But in the care transitions program that’s not what you need. You need a 30-

day intervention that’s a short-term relationship. You need to sell the program 

because people aren’t automatically going to want it. And so there was an 

element of selling.

And so the people that were high performing in their traditional role when it 

got flipped over to a Fee-for-Service struggled and it was because of these 

kinds of issues. Not understanding the connection between I got to hit my 

monthly target and our ability to make operations run. So hopefully that’s a 

little bit of a help.

So the next slide is really on building those right relationships and the right 

partnerships and I liked Roseanne’s start where you know people. That’s 

huge. I would also say start with the partners who are the influencers.
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Moderator: Lauren Solkowski

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In Cincinnati for us we needed to build a bridge to the healthcare community. 

We went to our local hospital association. They were the influencers in our 

community. We do the same things though in other areas. For example we 

need to build relationships in our counties and so for each county we sort of 

have a map of who are the influencers. Who are the people that can bring the 

other people to the table? And we’ve pinpointed them and strategically 

figured out how to build relationships with them.

So for example in Clermont County, it needs to be with Clermont Senior 

Services. In Warren County, we need to be with - they’ve got a business 

association that everybody attends. That’s where we need to be. And so it’s 

understanding who those people are and how to put yourself around them.

Other things that have helped with that as we moved forward with our role 

with the health council, it was defining those rules and responsibilities. What 

are you going to do versus what are we going to do and making sure that 

we’re not stepping on each other, but rather working in tandem.

And I loved the example that Roseanne gave about starting small and starting

with a pilot and being willing to invest something in that. That is exactly how 

we got our care transitions program up and running. It’s how we’re building 

partnerships and care coordination in the city. We’re piloting them, showing 

that it works, investing our own funds in that with the idea that we’ll get that 

back because we’re going to be able to price this product at a margin that is 

going to cover our startup, our research costs, and move us forward and be

able to grow and spread it.

And always working towards integration. That was just a lesson that we 

learned that, you know, it’s one thing to put something on paper and a flow 
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chart that says this is how we’re going to work together. It’s something 

entirely different to get it truly integrated and that’s where the real work is.

You know, having quality improvement teams where they’re cross functional 

and they can talk about issues and really talk about what - how to get this -

whatever this new service is integrated into the bigger healthcare system.

That’s where our work really needs to be focused once we figure out what the 

partnership is. And again its lots of TLC, lots of communication, and lots of 

time and energy spent on the relationship itself. So with that I think I’ve got 

one more slide which is just any questions or anything like that and as my 

husband said that tape is always (unintelligible) any question.

Lauren Solkowski: Thank you so much Sharon. I think - I know we’re right about 3:00, but I 

think we do want to take in a couple of questions so I’m going to turn it over 

to (Michelle) to open up the lines and queue up a few questions. In the 

meantime while she is doing that we had a few come in through chat. The first

being have either of you seen integrative or holistic health type services 

showing often any of these programs such as acupuncture, herbology, 

etcetera?

Roseanne Di Stefano: This is Roseanne. I really haven’t. I think the only thing that in 

terms of evidence-based programs that we offer that touches on that is the Tai 

Chi which teaches both balance and wellness. But there’s not been too much 

evidence-based done with those programs to my knowledge and so it’s hard to 

bring the data or to show the return on investment.

Lauren Solkowski: Okay great. Oh go ahead.

June Simmons: My experience would be go to the (unintelligible). I haven’t seen it with this 

particular population. I’ve seen it in others, but not in this particular one.
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Lauren Solkowski: Okay and then...

((Crosstalk))

Coordinator: I’m sorry to interrupt. I just wanted to let people know if they would like an 

open line they can press star 1 on their touch tone phone and make sure 

they’re unmuted and then record their name when prompted. Thank you.

Lauren Solkowski: Thanks (Michelle). And then we have another question here for Sharon. It 

sounds like you are using some of the good to great strategies for non-profits.

Do you think this is a good research for the group?

Sharon Fusco: Oh absolutely. It was actually - I wasn’t a part of the actual original 

restructuring, but it was required reading as I understand as they went through

this so I do believe that was one of the resources. And yes I do think it’s a 

very good resource.

Another book that I think is an excellent - actually there’s two other books 

that I would recommend, they are both by (Lafian) and one of them is called 

Play to Win and the other one is called the Non-Profit Strategy Revolution.

I’ve got it in my desk, I’m just double checking that that’s the name. Yes the 

Non-Profit Strategy Revolution and it’s by (David Lafian). And both of those 

books I think have really good - for non-profits who are entering the for profit 

market and can give you some really good information.

Lauren Solkowski: Excellent. Thank you. And then (Michelle) have we had any questions 

come in?

Coordinator: You do have two questions. Art your line is open.
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Art De Loreto: Yes, hi folks. This is Art De Loreto from the Pennsylvania Association of 

Area Agencies on Aging. It’s good to be with you all. And Sharon it’s very 

interesting to hear your presentation. We had an opportunity as you might 

know to hear from your CEO Suzanne Burke last week at our membership 

meeting and it’s really insightful to gain both of your perspectives.

We hear a lot as we look at business capacities and business acumen about, 

you know, the change of culture and you touched on a couple of things for 

that. I’m just wondering one of the things that we understand when an 

organization goes through cultural is that there is some down side and the 

downside becomes what typically is called casualties. You know, certain staff 

either are unable to perform or maybe realize that their work is not what they 

originally signed on for.

From your experience how did you continue to affect your cultural change 

while being able to give the staff that were affected some sense of stability 

and security and if you will confidence in them dealing with the personal sides 

or organizational change - the fears, the worries, the doubts, the defiance?

What did you - what do you recall were some of the things you were able to 

do?

Sharon Fusco: Well first I hope the perspectives were aligned. I have to say that. And you 

might have seen some similar wording here which is good because I think I 

stole some of her presentation for this. It’s a really great question and it’s not 

to be taken lightly. There is a down side in terms of - and I wouldn’t say a 

down side, it’s just as you shift your focus there are people whose personal 

value systems no longer are aligned with the organization’s values.
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And so they are placed - they’re in a situation where they have to make a 

choice either they are going to change their value system or they’re going to 

go to another position somewhere else. And we also saw that of course in our 

restructuring.

And I think the biggest think that helped particularly it started maybe with our 

restructuring, but it’s continued as we’ve gone into a huge area of uncertainty.

Our market is just changing so fast that it changes daily. So the biggest thing 

that we could do to help with fear is transparency so. And we were and have 

continued to be I should say very, very strategic about our employee 

communications. So when we went into our restructuring for example 

everybody heard the same message at the same time. That message was also 

transparent.

And as we continued to deal with the uncertainty that we have in the 

marketplace which is right now our biggest driver of fear, we are transparent.

This is what we know, this is what we don’t know. And we’re not withholding 

anything so that they are always hearing kind of a consistent message from all 

of us as our whole senior leadership team were always on the same page or 

always on message.

And so - and we have meetings where we sit down and say to prep for 

meetings to say what is our message. What is our common message? What are 

the things that everybody, you know, that we need to share. What is 

happening, you know, and how do we best communicate this. So those would 

be the things that I would say.

And the other thing is you have to be okay and you have to make your 

management staff okay with the idea that they may lose some of their people 

along this path, but that attrition is necessary. I liken it to I’ve had to trim off a 
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bunch of vines off of my grapes this past week so that I could get a good 

grape crop to come out. That’s part of - it’s part of the process and it’s not the 

most pleasant part, but it is part of it.

Art De Loreto: Very good. Thank you.

Coordinator: You have one more question from Leah. Your line is open.

Leah Eskenazi: Thank you. Roseanne and Sharon thank you so much for your presentations.

They’ve been very informative. I’m Leah Eskenazi from San Francisco with 

Family Caregiver Alliance. And I was curious if you in any of the business 

models that or dealings that you had did you propose doing services directed 

to informal caregivers? And because often it’s not part of the common 

discussion by healthcare providers.

Roseanne Di Stefano: This is Roseanne, I’ll jump in. Yes absolutely. I think working 

with the physicians around their patients. One of the things we do when we do 

an assessment they may identify somebody at risk, but they don’t know why.

And part of our assessing the whole situation is assessing the informal 

support, the strength or in some cases the problems around that. So it’s very 

much part of the picture that the physician doesn’t normally see and doesn’t

normally understand.

I would say in addition to that some of the evidence-based programs that we 

offer are focused on the caregiver to strengthen their resources and skills and 

that the physicians can be - are and again I’m talking physician groups, but it 

can be any healthcare provider - are very interested in empowering the 

informal support givers as well.
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Sharon Fusco: I would echo all of that. But the addition that I would have is a little bit more 

of a business perspective on it. And the difficulty that I see is that everybody 

agrees that it’s necessary, but nobody wants to pay for it.

Leah Eskenazi: Right.

Sharon Fusco: And that’s the biggest challenge. I mean we, you know, we had for example 

we have a manual - a caregiver manual that we developed and published. But 

is there a market actually out there to pay for it. And getting that manual out 

to the people who need it and are they willing to pay for those kinds of things, 

you know, that’s just not been something we - we tested that market and 

haven’t been able to find it.

We tested with - in our marketing stuff we went out and we tested the concept 

of caregiver support and just couldn’t get anybody (and) clients themselves 

necessarily interested in figuring out, you know, was there something that 

somebody would pay for or to get employers.

We several years ago approached employers about it and said hey you really 

need to think about this caregiver thing because guess what? In the State of 

Ohio $17 billion a year you’re losing in productivity hours because people are 

home taking care of their older adults. That’s a huge profit issue - bottom line 

issue. And still couldn’t get anybody interested in it in paying for it. So it’s 

one of those things where I think if we can figure out how to package it in a 

way, you know, to make it profitable for us that would be awesome. But 

who’s going to pay for it?

Lauren Solkowski: Great.
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Sharon Fusco: And (I mean) and it’s not that we don’t do it. I mean we do caregivers

assessments and we do education, but we figure out to fund those from the 

extra funding that we have. So, you know, it’s something we’re investing in 

even though there isn’t anybody paying for it.

June Simmons: Yes, I agree. We’ve run into some of the similar issues. Thank you so much.

((Crosstalk))

Lauren Solkowski: I’m sorry. What was that (Michelle)?

Coordinator: I just wanted to let you know there were no more questions on the phone.

Lauren Solkowski: Okay. Thank you. And I think with that we are a little bit over our time so 

I do want to thank - many thanks to both Roseanne and Sharon for presenting 

on today’s webinar.

This was very informative and I hope that our sites were - this is helpful for 

them. And also a big thanks to June and as well as the Hartford Foundation for 

sharing their announcement and we’re thrilled to be working with them on this

grant.

If there are questions that you did not get answered today, please feel free to 

email them to me and I will make sure that we follow up with you. And I 

think with that we’re done. So thank you again to everyone for joining us 

today.

END