COVID's impact on behavioral health: Solutions for state agencies

Read this if your company is considering outsourced information technology services.

For management, it’s the perennial question: Keep things in-house or outsource?

For management, it’s the perennial question: Keep things in-house or outsource? Most companies or organizations have outsourcing opportunities, from revenue cycle to payment processing to IT security. When deciding whether to outsource, you weigh the trade-offs and benefits by considering variables such as cost, internal expertise, cross coverage, and organizational risk.

In IT services, outsourcing may win out as technology becomes more complex. Maintaining expertise and depth for all the IT components in an environment can be resource-intensive.

Outsourced solutions allow IT teams to shift some of their focus from maintaining infrastructure to getting more value out of existing systems, increasing data analytics, and better linking technology to business objectives. The same can be applied to revenue cycle outsourcing, shifting the focus from getting clean bills out and cash coming in, to looking at the financial health of the organization, analyzing service lines, patient experience, or advancing projects.  

Once you’ve decided, there’s another question you need to ask
Lost sometimes in the discussion of whether to use outsourced services is how. Even after you’ve done your due diligence and chosen a great vendor, you need to stay involved. It can be easy to think, “Vendor XYZ is monitoring our servers or our days in AR, so we should be all set. I can stop worrying at night about our system reliability or our cash flow.” Not true.

You may be outsourcing a component of your technology environment or collections, but you are not outsourcing the accountability for it—from an internal administrative standpoint or (in many cases) from a legal standpoint.

Beware of a false state of confidence
No matter how clear the expectations and rules of engagement with your vendor at the onset of a partnership, circumstances can change—regulatory updates, technology advancements, and old-fashioned vendor neglect. In hiring the vendor, you are accountable for oversight of the partnership. Be actively engaged in the ongoing execution of the services. Also, periodically revisit the contract, make sure the vendor is following all terms, and confirm (with an outside audit, when appropriate) that you are getting the services you need.

Take, for example, server monitoring, which applies to every organization or company, large or small, with data on a server. When a managed service vendor wants to contract with you to provide monitoring services, the vendor’s salesperson will likely assure you that you need not worry about the stability of your server infrastructure, that the monitoring will catch issues before they occur, and that any issues that do arise will be resolved before the end user is impacted. Ideally, this is true, but you need to confirm.

Here’s how to stay involved with your vendor
Ask lots of questions. There’s never a question too small. Here are samples of how precisely you should drill down:

• What metrics will be monitored, specifically?
• Why do the metrics being monitored matter to our own business objectives?
• What thresholds must be met to notify us or produce an alert?
• What does exceeding a threshold mean to our business?
• Who on our team will be notified if an alert is warranted?
• What corrective action will be taken?

Ask uncomfortable questions
Being willing to ask challenging questions of your vendors, even when you are not an expert, is critical. You may feel uncomfortable but asking vendors to explain something to you in terms you understand is very reasonable. They’re the experts; you’re not expected to already understand every detail or you wouldn’t have needed to hire them. It’s their job to explain it to you. Without asking these questions, you may end up with a fairly generic solution that does produce a service or monitor something, but not necessarily all the things you need.

Ask obvious questions
You don’t want anything to slip by simply because you or the vendor took it for granted. It is common to assume that more is being done by a vendor than actually is. By asking even obvious questions, you can avoid this trap. All too often we conduct an IT assessment and are told that a vendor is providing a service, only to discover that the tasks are not happening as expected.

You are accountable for your whole team—in-house and outsourced members
An outsourced solution is an extension of your team. Taking an active and engaged role in an outsourcing partnership remains consistent with your management responsibilities. At the end of the day, management is responsible for achieving business objectives and mission. Regularly check in to make sure that the vendor stays focused on that same mission.

Is your state Medicaid agency considering a Centers for Medicare and Medicaid Services (CMS) Section 1115 Waiver to fight the opioid epidemic in your state? States want the waiver because it provides flexibility to test different approaches to finance and deliver Medicaid services. The skyrocketing prevalence of substance use disorders nationwide calls for such flexibility and innovation to expand existing services for treatment and recovery. Although applying for an 1115 waiver can be daunting, here are some guidelines to help you succeed with implementation.

Be pragmatic
Be honest and pragmatic in planning discussions for the essential resources you need to have in place for a successful implementation. Ask yourselves who and how many people you need to involve to develop and execute each stage. Plan enough time to develop policies and agency protocols, make sure you have the right providers for your members, set provider rates, and then train the providers.

Ask hard questions
Once you identify key requirements to address first in your waiver, ask yourself what elements need to be in place to meet these requirements. Here are elements to consider and questions to answer:

• Fee-for-service and managed care organization (MCO) rates — new services, such as adult residential treatment services aligned with care standards (e.g., American Society of Addiction Medicine (ASAM®) levels), may require changes to reimbursement rates. What needs to happen to develop new rates? What obstacles do you anticipate and how will you overcome them?
• Care standards (e.g., ASAM® levels of care) and training your providers — consider what the levels mean given the range of providers in your state and the services your members receive. What is required to move to these standards? How you will work with providers to ensure adherence, including certification and training? What will this cost?
• Policy changes — your state’s Medicaid agency will need to revamp and create policies to cover the service expansion and other changes. How will you complete all necessary policy and protocol changes early enough to inform MCO and provider actions?
• MCO provider network adequacy — it’s worth investing the time in your application development to assess whether the MCOs serving Medicaid recipients in your state have the right mix of providers to ensure that you can fully implement the new service structure. How long should you give the MCOs for network expansion or recruitment?
• MCO care coordination guidelines — each MCO will have its own approach. How are you going to ensure adherence to your waiver’s vision of care coordination?
• Indicators — how will you evaluate the success of your program? How will you collect and analyze data? The earlier you determine how you will evaluate your program, the easier it will be to report on, and make improvements.

Get started
Applying for and implementing an SUD 1115 waiver is a complex and time-consuming process — but by dedicating the time up front to address the many details of time and resources, you’ll find implementation to be far smoother, and effective treatment and recovery services provided sooner for those who need it most. Our Medicaid team is here to help.

People are naturally resistant to change. Employees facing organizational change that will impact day-to-day operations are no exception, and they can feel threatened or fearful of what that change will bring. Even more challenging are multiyear initiatives where the project’s completion is years away.

How can your agency or organization help employees prepare for change—and stay motivated for an outcome—many years in the making?

Start With the Individual

Organizational change requires individual change. For the change to be successful and lasting, an agency should apply organizational change management strategies that help lead people to your desired outcome.

With any new project or initiative, people need to understand why the project is happening before they support it. Communicate the reasons for the change—and the benefit to the employee (what’s in it for them)—so each individual is more inclined to actively support the project. Clearly communicating the why at the onset of the project can help employees feel vested in, and part of, the change. As Socrates said, “The secret of change is to focus all your energy, not on fighting the old, but building the new.” A clear vision can inspire each employee’s desire for the “new” to succeed.

Shift to Individual Goals

It’s a challenge to maintain your employees’ motivation for an organizational change occurring over the long haul. Below are some suggestions on how to sustain interest and enthusiasm for multi-year projects:

1. Break the project down into smaller, specific milestones. Short-term goals highlight important deadlines and create tangible progress points to reach and celebrate. The master project schedule should be an integration of the organizational change management plan and the project management plan so any resource constraints you identify in the project management plan also become an input when identifying change management resources and activity levels. This integration also highlights the importance of key organizational change management milestones and activities in an effort to ensure they are on a parallel tack as traditional project tasks.
2. Effectively communicate status updates and successes. In large, agency-wide projects, there are often a variety of stakeholders, each with different communication expectations and needs. The methods, content, and frequency of communication will vary accordingly. Develop a communications strategy as part of your organizational change management plan, to identify who will be responsible to send communications, when and how they will be sent, key messages of the communications, and what feedback mechanisms are in place to continue the conversation after initial delivery. For example, the project team needs a different level of detail than the legislature, or the public. Making the content relevant to each stakeholder group is important because it gives each group what they need to know so they don’t drown in a flood of unneeded information.
3. Create buy-in by involving employees. A feeling of ownership naturally results from participation in a project, which helps increase enthusiasm. Often the time to do this is when discussing changes to business processes. Once you determine the mandatory features of the future state, (e.g., financial controls, legal requirements, legislative mandates) consider including stakeholder feedback on decisions more focused on preference. It is important for stakeholders to see their suggestions accepted and implemented, or if not implemented, that there was at least a structured process for thoughtfully considering their feedback, and a business case for why their suggestions didn’t make it into the project.
4. Conduct lessons learned assessments after each major milestone. The purpose of conducting lessons learned activities is to capture what worked and what didn’t. Using surveys or other feedback systems, such as debrief meetings, allows stakeholders to voice their thoughts or concerns. By soliciting feedback after each milestone, leadership can quickly adapt to challenges, address any misunderstandings or concerns, and capitalize on successes.
5. Reinforce how the project meets the goals of the agency or organization. Maintaining enthusiasm and support for a long-term goal takes a constant reminder of the overall organizational goals. It is important for senior leadership to communicate the impact of the project on the agency or organization and to stakeholders and keep the project at the forefront of people’s minds. Project goals may change during the duration of the project, but the project sponsor should continue to be active and visible in communicating the goals and leading the project.

Change is difficult—change that is years in the making is even more challenging. Applying a structured organizational change management process and using these tips can help keep employees energized and help ensure you reach the desired project goals.

While new software applications help you speed up processes and operations, deciding which ones will work best for your organization can quickly evolve into analysis paralysis, as there are so many considerations.

Case in point: Software as a Service (SaaS) model
The benefits of the SaaS model, in which a vendor remotely hosts an organization’s applications, are fairly well known: your organization doesn’t have to shell out for costly hardware, the vendor tackles upgrades, backups, data recovery, and security, and you have more time and money to focus on your business goals.

There are multiple factors to look at when determining whether a SaaS solution is right for you. We’ve compiled a list of the top three SaaS considerations:

1. Infrastructure and capacity
Your organization should consider your own people, processes, and tools when determining whether SaaS makes sense. While an on-site solution may require purchasing new technologies, hiring new staff, and realigning current roles and responsibilities to maintain the system, maintaining a SaaS solution may also require infrastructure updates, such as increased bandwidth to sufficiently connect to the vendor's hosting site.

Needless to say, it’s one thing to maintain a solution; it’s an entirely different thing to keep it secure. An on-site hosting solution requires constant security upgrades, internal audits, and a backup system—all of which takes time and money. A SaaS model requires trust in your vendor to provide security. Make sure your potential vendor uses the latest security measures and standards to keep your critical business data safe and secure.

2. Expense
When you purchase major assets—for example, hardware to host its applications—it incurs capital expenses. Conversely, when you spend money on day-to-day operations (SaaS subscriptions), it incurs operating expenses.

You should weigh the pros and cons of each type of expense when considering a SaaS model. On-site upfront capital expenses for hosting hardware are generally high, and expenses can spike overtime when you update the technology, which can be difficult to predict. And don’t forget about ongoing costs for maintenance, software upgrades, and security patches.

In the SaaS model, you spread out operating costs over time and can predict costs because you are paying via subscription—which generally includes costs for maintenance, software upgrades, and security patches. However, remember you can depreciate capital expenses over time, whereas the deductibility of operating expenses are generally for the year you use them.

3. Vendor viability
Finally, you need to conduct due diligence and vet SaaS vendors before closing the deal. Because SaaS vendors assume the responsibility for vital processes, such as data recovery and security, you need to make sure the potential vendor is financially stable and has a sustainable business model. To help ensure you receive the best possible service, select a vendor considered a leader in its market sector. Prepare a viable exit strategy beforehand so you can migrate your business processes and data easily in case you have any issues with the SaaS provider.

You must read—and understand—the fine print. This is especially important when it comes to the vendor’s policies toward data ownership and future migrations to other service providers, should that become necessary. In other words: Make sure you have final say and control over your data.

Every organization has different aspects of their situation to consider when making a SaaS determination. Want to learn more? It’s a snap! Contact the authors: Clark Lathrum and Matthew Tremblay. 

Good Practices Are Not Enough

When it comes to IT security, more than one CEO running a small organization has told me they have really good people taking care of “all that.” These CEOs choose to believe their people perform good practices. That may be true, but who defines good practices and how they administer them? And when? If “security is everyone’s job,” then nobody is responsible for getting specific things done. Good practices require consistency, and consistency requires structure.

From an audit perspective, a control not written down does not exist. Why? Because it can’t be tested, measured, or validated. An IT Auditor can’t assess controls if they were never defined. Verbal instruction carries by far the most risk. “I told him to do that,” doesn’t pass the smell test in court.

Why Does it Matter?

Because it’s not IT’s job to write policies. Their job is to implement IT decisions made by management. They’re not at the right level to make decisions that impact the entire organization. Why should small organizations concern themselves with developing policies and procedures? Here are two very good reasons:

1. Regulatory Requirements
2. Lawsuits

No matter how small your organization, if you have a corporate network (even cloud-based) and you store credit card transactions, personal health information, client financial information or valuable intellectual property, being aware of state and federal regulatory requirements for protecting that information is vital. It is the responsibility of management to research and develop a management framework for addressing risk.

Lawsuits happen when information is stolen and/or employees are terminated for inappropriate activities. If you have no policies that mandate what is and isn’t acceptable, and what the penalties are for violations, your terminated employee has grounds for a wrongful termination lawsuit: policy should not be written by the IT Department.

If confidential data you are responsible for is stolen and clients sue you, standing up in court and saying “We don’t have any written policies or procedures,” is a sure way to have both significant financial losses and a negative impact on your reputation. For a small organization, that could mean going out of business.

Even if data is stolen from a third-party vendor who stores your data, your organization owns the data and is responsible for ensuring the data is secure with the vendor and meets organizational requirements. Do you have a vendor management policy? If you work with vendors, you need one.

Consider, too, that every organization expects to grow its business. The longer management doesn’t pay attention to policies and procedures, the more difficult it becomes to develop and implement them.

Medium and Large Organizations Need to Pay Attention, too

A policy document provides a framework for defining activities and decision-making by everyone in the organization. A policy contains standards for the organization, and outlines penalties for non-performance. The organization’s management team or board of directors must drive their creation.
Policies also maintain accountability in the eyes of internal and external stakeholders. Even the smallest organization wants their customers and employees to have confidence the organization is protecting important information. By defining the necessary controls for running business operations that address risk and compliance requirements (and reviewing them annually), your management team demonstrates a commitment to good practices.

Procedures are the “How”

Procedures don’t belong in a policy. Departments need to be able to design their own procedures to meet policy requirements and definitions. HR will have procedures for employee privacy and financial information, finance must manage credit card, student, banking or client financial documentation, and IT will need to develop specific technical procedures to document their compliance with policy.

If all those procedures are in a policy, it makes for unwieldy policy documents that management must review and approve. Departments need to change and update their procedures quickly in order to remain effective. For example, a policy may mandate the minimum number of characters in a password, but IT needs to develop the procedures to implement that requirement on many platforms and devices.

What is a “Plan” Used For?

Consider that organizations commonly have a Business Continuity Plan as well as an Incident Response Plan. How is a “plan” different from a policy or procedure?

A plan (for example, an Information Security Plan, or Privacy Plan, etc.) is a collection of related procedures with a specific focus. I have seen these collections called “programs,” but most organizations use “plan” (plus, the Federal government uses that term). The term “program” implies a beginning and an end, as well as tending to be a little too generic (think “School Lunch Program”).

Three Ways Not to Develop Policies, Procedures and Plans

Consider the Unique Aspects of Your Organization

What electronic information does your organization consider valuable? During an assessment with a state university, we discovered that the farm research the agriculture school was performing was extremely valuable. While we started out with questions about student health and financial information, the university realized the research data was equally critical. The information might not have federal or state regulations attached to it, but if it is valuable to your organization, you need to protect it. By not taking a one-size fits all approach to our assessment, we were able to meet their specific needs.

Multiple Departments or Locations? Standardize.

Whether your organization is a university, non-profit organization, government agency, medical center or business, you frequently have sub-entities. Each sub-entity or location may have different terms for different functions. For example, at a recent engagement for another university, Information Security “Programs,” “Plans” and “Policies” meant different things on different campuses. This caused confusion on the part of all stakeholders. It also showed a lack of cohesion in the approach to security of the university as a whole. Standardizing language is one of the best ways to have everyone in the organization on the same page, even if the documents are unique to a location, agency or site. This makes planning, implementation, and system upgrade projects run more effectively.

Demonstrate Competence

No matter what terms your organization chooses, using consistent terms is a good way to demonstrate a thoughtful approach. Everyone needs to be talking the same language. Having documents that specify management decisions provides assurance to internal and external stakeholders. Good policies, procedures and plans can mean the difference between a manageable crisis and a business failure.

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Most of us have been (or should have been) instructed to avoid using clichés in our writing. These overstated phrases and expressions add little value, and often only increase sentence length. We should also avoid clichés in our thinking, for what we think can often influence how we act.

Consider, for example, “death by committee.” This cliché has greatly — and negatively — skewed views on the benefits of committees in managing projects. Sure, sometimes committee members have difficulty agreeing with one another, which can lead to delays and other issues. In most cases, though, an individual can’t possibly oversee all aspects of a project, or represent all interests in an organization. Committees are vital for project success — and arguably the most important project committee is the steering committee.

What Exactly is a Steering Committee?
It is a group of high-level stakeholders that provides strategic direction for a project, and supports the project manager. Ideally, the group increases the chances for project success by closely aligning project goals to organizational goals. However, it is important to point out that the group’s top priority is project success.

The committee should represent the different departments and agencies affected by the project, but remain relatively small in size, chaired by someone who is not an executive sponsor of the project (in order to avoid conflicts of interest). While the project manager should serve on the steering committee, they should not participate in decision-making; the project manager’s role is to update members on the project’s progress, areas of concern, current issues, and options for addressing these issues.

Overall, the main responsibilities of a steering committee include:

1. Approving the Project Charter
2. Resolving conflicts between stakeholder groups
3. Monitoring project progress against the project management plan
4. Fostering positive communicating about the project within the organization
5. Addressing external threats and issues emerging outside of the project that could impact it
6. Reviewing and approving changes made to the project resource plan, scope, schedules, cost estimates, etc.

What Are the Pros and Cons of Utilizing a Steering Committee?
A group of executive stakeholders providing strategic direction should benefit any project. Because steering committee members are organizational decision-makers, they have the access and credibility to address tough issues that can put the project at a risk, and have the best opportunities to negotiate positive outcomes. In addition, steering committees can engage executive management, and make sure the project meshes with executive management’s vision, mission, and long-range strategic plan. Steering committees can empower project managers, and ensure that all departments and agencies are on the same page in regards to project status, goals, and expectations. In a 2009 article in Project Management Journal, authors Thomas G. Lechler and Martin Cohen concluded that steering committees are important to implementing and maintaining project management standards on an operational level — not only do steering committees directly support project success, they are instrumental in deriving value from an organization's investments in its project management system.

A steering committee is only as effective as it’s allowed to be. A poorly structured steering committee that lacks formal authority, clear roles, and clear responsibilities can impede the success of a project by being slow to respond to project issues. A proactive project manager can help the organization avoid this major pitfall by helping develop project documents, such as the governance document or project plan that clearly define the steering committee structure, roles, responsibilities and authority.

Steer Toward Success!
Steering committees can benefit your organization and its major projects. Yet understanding the roles and responsibilities — and pros and cons — is only a preliminary step in creating a steering committee. Need some advice on how to organize a steering committee? Want to learn more about steering committee best practices? Together, we can steer your project toward success.

A year ago, CMS released the Medicaid Enterprise Certification Toolkit (MECT) 2.1: a new Medicaid Management Information Systems (MMIS) Certification approach that aligns milestone reviews with the systems development life cycle (SDLC) to provide feedback at key points throughout design, development, and implementation (DDI).

The MECT (recently updated to version 2.2) incorporates lessons learned from pilot certifications in several states, including the successful West Virginia pilot that BerryDunn supported. MECT updates have a direct impact on E&E systems—an impact that may increase in the near future. Here is what you need to know:         

Then: Initial Release

In February 2017, CMS introduced six Eligibility & Enrollment (E&E) checklists. Five were leveraged from the MECT, while the sixth checklist contained unique E&E system functionality criteria and provided a new E&E SDLC that—like the MECT—depicted three milestone reviews and increased the Independent Verification and Validation (IV&V) vendor’s involvement in the checklists completion process.

Now: Getting Started

Completing the E&E checklists will help states ensure the integrity of their E&E systems and help CMS guide future funding. This exercise is no easy task, particularly when a project is already in progress. Completion of the E&E checklists involves many stakeholders, including:

• The state (likely more than one agency)
• CMS
• IV&V
• Project Management Office (PMO)
• System vendor(s)

As with any new processes, there are challenges with E&E checklists completion. Some early challenges include:

• Completing the E&E checklists with limited state project resources
• Determining applicable criteria for E&E systems, especially for checklists shared with the MMIS
• Identifying and collecting evidence for iterative projects where criteria may not fall cleanly into one milestone review phase
• Completing the E&E checklists with limited state project resources
• Working with the system vendor(s) to produce evidence

What’s Next?

Additionally, working with system vendors may prove tricky for projects that already have contracts with E&E vendors, as E&E systems are not currently subject to certification (unlike the MMIS). This may lead to instances where E&E vendors are not contractually obligated to provide the evidence that would best satisfy CMS criteria. To handle this and other challenges, states should communicate risks and issues to CMS and work together to resolve or mitigate them.

As CMS partners with states to implement the E&E checklists, some questions are expected to be asked. For example, how much information can be leveraged from the MECT, and how much of the checklists completion process must be E&E-specific? Might certification be required in the near future for E&E systems?

While there will be more to learn and challenges to overcome, the first states completing the E&E checklists have an opportunity to lead the way on working with CMS to successfully build and implement E&E systems that benefit all stakeholders.

On July 31, 2017, CMS released the MECT 2.2 as an update to the MECT 2.1.1. As the recent changes continue to be analyzed, what will the impact be to current and future MMIS and E&E projects?

Check back here at BerryDunn Briefings in the coming weeks and we will help you sort it out.

We all know them. In fact, you might be one of them — people who worry the words “go live” will lead to job loss (theirs). This feeling is not entirely irrational. When an organization is ready to go live from an existing legacy system to a new enterprise system, stress levels rise and doubts emerge: What can go wrong? How much time will be lost? Are we really ready for this?

We’re here to help. Here is a list of go-live essentials to help you mitigate stress and assess your readiness. While not all-encompassing, it’s a good place to start. Here’s what you need:

1. A detailed project plan which specifies all of the implementation tasks
   A project plan is one of the most important parts of an implementation. A detailed plan that identifies all of the implementation tasks along with an assigned resource for each task is critical to success. The implementation vendor and the organization should develop this plan together to get buy-in from both teams.

2. A completed system configuration
   New system configuration is one of the most time-consuming aspects of a technology implementation. If you don’t complete the implementation in a timely manner, it will impact your go-live date. Configure the new system based upon the best practices of the system — not how the existing system was — for timely implementation.

3. External system interface identification
   While replacement of some external systems may be a goal of an implementation, there may be situations where external systems are not replaced or the organization has to send and/or receive data from external organizations. And while new systems have advanced interface technology capabilities, the external systems may not share these capabilities. Therefore it is imperative that you identify external system interfaces to avoid gaps in functionality.

4. Testing, testing, testing
   End-to-end testing or User Acceptance Testing (UAT) is often overlooked. It involves completing testing scenarios for each module to ensure appropriate system configuration. While the timing of UAT may vary, allow adequate time to identify solutions to issues that may result from UAT.

5. Data conversion validation
   When you begin using a new system, it’s best to ensure you’re working with clean, up-to-date data. Identify data conversion tasks in the project plan and include multiple data conversion passes. You must also determine if the existing data is actually worth converting. When you complete the data conversion, check for accuracy.

6. End user training
   You must train all end users to ensure proper utilization across the organization. Don’t underestimate the amount of time needed for end user training. It is also important to provide a feedback mechanism for end users to determine if the training was successful.

7. A go-live cutover plan
   The overall project plan may indicate go-live as an activity. List specific activities to complete as part of go-live. You can build these tasks into the project plan or maintain them as a separate checklist to promote a smooth transition.

8. Support structure
   Establish an internal support structure when preparing for go-live to help address issues that may arise. Most organizations take time to configure and test the system and provide training to end users prior to go-live. Questions will arise as part of this process — establish a process to track and address these questions.

Technology implementations can significantly impact your organization, and it’s common for stress levels to rise during the go-live process. But with the right assessment and preparation, you can lessen their impact and reduce staff stress. Our experienced, objective advisors work with public and private sector organizations across the country to oversee large enterprise projects from inception to successful completion. Please reach out to us to learn more about preparing for your next big project.