Economic Management: Maximizing Organizational Effectiveness (part 5 - The Podcast)

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Leading Human Resources: An Analysis (part 25)

Implementation---Getting from Here to There

by

Charles Lamson

The implementation process involves the following: identifying alternative solutions and appropriate implementation strategies; anticipating the probable consequences of each of the alternative strategies; and choosing a specific strategy and implementing it.

This stage of the change process involves the translation of diagnostic data into change goals and plans, strategies, and procedures. Questions such as the following must be asked: How can change be effected in a work group or organization, and how will it be received? What is adaptive, and what is resistant to change within the environment?

Once your analysis is completed, the next step is to determine alternative solutions to the problem(s). Hand in hand with developing alternative solutions is determining appropriate implementation strategies. Three approaches are helpful in the implementation process: Lewin's change process and force field analysis and Schein's idea of psychological safety. This post will focus on Lewin's change process

Lewin's Change Process

In examining change, Kurt Lewin identified three phases of the change process---unfreezing, changing, and refreezing.

Unfreezing

The aim of unfreezing is to motivate and make the individual or the group ready to change. It is a thawing-out process in which the forces acting on individuals are rearranged so that now they see the need for change. According to Schein, when drastic unfreezing is necessary, the following common elements seem to be present: (1) The individuals being changed are physically removed from the accustomed routines, sources of information and social relationships; (2) all social supports are undermined and destroyed; (3) the individuals being changed are demeaned and humiliated so that they will see their old attitudes or behavior as unworthy and thus be motivated to change; (4) reward is consistently linked with unwillingness to change.

Changing

Once individuals have become motivated to change, they are ready to be provided with new patterns of behavior. This process is most likely to occur by one of two mechanisms: identification or internalization. Identification occurs when one or more models are provided in the environment---models from whom individuals can learn new behavior patterns by identifying with them and trying to become like them. Internalization occurs when individuals are placed in a situation in which new behaviors are demanded of them. They learn these new behavior patterns not only because they are necessary for survival, but also because new high-strength needs are induced by coping behavior.

Internalization is a more common outcome in those influence settings where the direction of change is left more to the individual. The influence that occurs in programs such as Alcoholics Anonymous, in psychotherapy or counseling for hospitalized or incarcerated populations, in religious retreats, in human relations training, . . . and in certain kinds of progressive education programs is more likely to occur through internalization or, at least, to lead ultimately to more internalization.

Identification and internalization are not either/or courses of action. Rather, effective change is often the result of combining the two into a strategy for change.

Compliance is sometimes discussed as another mechanism for inducing change. It occurs when an individual is forced to change by the direct manipulation of rewards and punishment by someone in a power position. In this case, behavior appears to have changed when the change agent is present, but it is often dropped when supervision is removed. Thus, rather than discussing force or compliance as a mechanism of changing, we should think of it as a tool for unfreezing.

Refreezing

The process by which the newly acquired behavior comes to be integrated as patterned behavior into the individual's personality or ongoing significant emotional relationships is referred to as refreezing. According to Schein, if the new behavior has been internalized while being learned, "this has automatically facilitated refreezing because it has been fitted naturally into the individual's personality. It has been learned through identification, it will persist only so long as the target's relationship with the original influence model persists, unless new surrogate models are found or social support and reinforcement are obtained for expressions of the new attitudes."

This statement highlights how important it is for an individual engaged in a change process to be in an environment that continually reinforces the desired change. The effect of many training programs has been short-lived when the person returns to an environment that does not reinforce the new patterns or, even worse, is hostile toward them.  

*SOURCE: MANAGEMENT OF ORGANIZATIONAL EFFECTIVENESS: LEADING HUMAN RESOURCES, 8TH. ED., 2001, PAUL HERSEY, KENNETH H. BLANCHARD, DEWEY E. JOHNSON, PGS. 380-382*

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How to Start a Home Care Business: The Proposal (part 10)

CONSUMER DIRECTED SERVICES’ GENERAL INFORMATION

CONSUMER DIRECTED SERVICES (CDS) include: 

• State Plan Personal Care, which includes but is not limited to: 
• Personal Care – bathing, grooming, dressing, personal hygiene 
• Toileting – ostomy or catheter hygiene; bowel and/or bladder routine; general toileting activities 
• Health – use of transfer devices/mobility issues/prostheses, passive range of motion, manual assistance with medications, treatments, cleaning and maintenance of equipment
• Housekeeping – cleaning, dusting, bed linens, laundry, trash
• Meals – meal preparation and/or assistance with eating, washing dishes 
• Transportation – essential shopping/errands, school or employment

CONSUMER DIRECTED SERVICES PROPOSAL FOR CONTRACT

The following information must be submitted to be considered for a participation agreement (contract) to provide consumer directed services. In order for the Missouri Medicaid Audit and Compliance Unit (MMAC) to conduct an efficient review of the business entity’s proposal, the proposal must meet the requirements as outlined in the Proposal Submission Requirements (see How to Start a Home Care Business (part 9)). 

Section I: Forms

1. CDS Proposal Checklist
2. Vendor Profile
3. Service Area Commitment (SAC) indicating the geographic areas (counties) the applying provider plans to serve.
4. Business Organizational Structure (BOS) and all required documents as indicated by the section of the form completed

Section II: Business Documentation

1. Notification from the Internal Revenue Service of the business entity’s Federal Employer Identification Number.
2. Notification from the Missouri Department of Revenue of the business entity’s Missouri Employer Identification Number.
3. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at https://dor.mo.gov/forms/943.pdf.
4. The e-mailed verification of registration received from the Missouri Office of Administration (OA) (https://missouribuys.mo.gov/). Minimum registration required is “Standard” (no fee). Do not submit anything if the name, address and federal employer identification number are already registered with OA.
5. Copy of EVV (Electronic Visit Verification or Telephony) contract. A quote is acceptable during the proposal process, but a contract must be in place prior to the final approval for participation. Refer to RSMo 208.909.1.
6. National Provider Identification Number (NPI). Information is available at https://nppes.cms.hhs.gov/#/. You must register under the business name as an 02-Organizational Entity
7. Business license. If a business license is not required submit a statement of explanation.
8. Lease agreement or deed for the office location.

Section III: Business Plan

Applying vendors must assure the MMAC that sufficient financial resources exist to provide continuous service to consumers. The use of a business plan will help entities manage their business and ensure financial stability. For assistance in developing a business plan, contact the Missouri Business Assistance Center (MBAC) at 573/751-2863 for a complete start-up package or information is available on their website at www.missouribusiness.net. At a minimum, the Business Plan must include the following information: 

Company - Correct legal name of entity as filed with the Missouri Secretary of State, Internal Revenue Service (“IRS”) and Missouri Department of Revenue (“DOR”) and used throughout the proposal. Description of the entity including if it is new or existing, its history, purpose, etc. 

Office/Plant - Office address and description of area and building. State whether the office is rented, leased or owned. If the business is located in a home, describe the space that is dedicated exclusively for business. Describe how the location meets the Americans with Disabilities Act’s accessibility requirements. 

Personnel - Describe how personal care attendants will be recruited to provide direct care. 

• Describe how employees will be recruited for administrative and billing functions. 
• Describe the prior experience or education that qualifies management to run this type of business. 

Marketing - Describe the local market for this service. 

• Describe the methods to be used to obtain consumers in this market. 
• Describe what efforts, if any, will be used to expand beyond the local market. 
• Describe what kind of payments will be sought (Medicaid reimbursement, Medicare, private pay, etc)

Financial Management – Describe a plan for management of the financial resources of the entity. 

• Describe the qualifications of the person(s) handling the financial matters of the entity. Include the name(s) of the individual(s). 
• Include a budget for starting the business and projected operating costs for the first year of operation. 
• Identify the sources of revenue to be used to start the business. 
• State how the agency will be able to provide fiscal conduit services (continuously meet financial responsibilities prior to state reimbursement).

Section IV: Training

Submit a detailed training and orientation plan for participants that meet the requirements of 19 CSR 15-8.400. Do not submit training materials to be used. Provide a copy of the agenda outlining each topic to be trained.

Section V: Policies and Procedures

1. Philosophy for promoting the consumer’s ability to live independently in the most integrated setting or the maximum community inclusion of participants with physical disabilities in compliance with 19 CSR 15-8.400.  
2. Policy and procedures for maintaining telephone contact with state agencies and participants during business hours and after business hours in compliance with the Program Requirements. 
3. Policy and procedures for notifying participants of any changes in vendor’s telephone number, address, and/or posted business hours in compliance with the Program Requirements. 
4. Policy and procedures for quality assurance and supervision process that will ensure program compliance and accuracy of records in compliance with 19 CSR 15-8.400. 
5. Policy and procedures regarding elder abuse, neglect and exploitation including identification and reporting in compliance with 192.2400 – 192.2475 RSMo; 19 CSR 15-8.400, and the Program Requirements. 
6. Policy and procedures for preventing and detecting conduct or actions that are improper or abusive of the MO HealthNet program, including reporting or resolution of improper or abusive conduct in compliance with 19 CSR 15-8.400 and 13 CSR 70-3.030. Improper conduct or actions include, but not limited to, misappropriation of participant property and/or funds, falsification of service delivery documents, falsification of agency records, etc.  
7. Policy and procedures for suspending and closing services to participants in compliance with 19 CSR 15-8.400. 
8. Policy and procedures for hiring personal care attendants in compliance with 19 CSR 15-8.400 and the Program Requirements.  
9. Policy and procedures for maintaining participant files in compliance with 19 CSR 15-8.400, and Program Requirements.  
10. Policy and procedures for filing claims for Medicaid reimbursement in compliance with 19 CSR 15-8.400.  
11. Policy and procedures for performing payroll functions on behalf of participants in compliance with 19 CSR 15-8.400 and the Program Requirements. 
12.  A copy of the employment application to be completed by personal care attendants. The application must be in compliance with the Program Requirements. 
13. Policy and procedures for ensuring personal care attendants are registered, screened and employable per the Family Care Safety Registry (FCSR) in compliance with 19 CSR 15-8.400, and the Program Requirements. 
14. Policy and procedures for screening personal care attendants against the Employee Disqualification List (EDL) in compliance with 192.2490.1 RSMo and the Program Requirements.

Section VI: Assurances

Complete both pages of the Consumer Directed Services Assurances form. No additional documentation needs to be submitted with this form. However, applying vendor’s policies and procedures must incorporate the assurances noted in items #4 through #21.

Section VII: Screening Documentation

Include in your proposal, a list of the exact name, date of birth and social security number(s) used, for all of the individuals listed below for screening purposes. 

• All owners with more than 5% direct or indirect ownership or control interest, all corporate Officers, Directors, and members of LLCs.  
• Executive Director and CDS Coordinator  
• Each individual listed on the Business Organizational Structure 
• Managing Employees” as defined in 13 CDS 65-2.010(21) 

Registration with Family Care Safety Registry (FCSR) is required for individuals that will have direct contact with Medicaid participants, including but not limited, to those listed above. The registration should now be completed online. Visit https://health.mo.gov/safety/fcsr/ for the online registry and instructions. Include the FCSR registration from DHSS with your proposal.

Section VIII: Confirmation of CDS Orientation Attendance

Any CDS proposal submitted after March 1, 2019, you must submit a copy of the Ceritficate of Attendance for the CDS Orientation Training. Proposals will not be reviewed by MMAC until documentation of attendance is submitted.

Submit the Completed Proposal To

Mailing Address: 

Missouri Medicaid Audit and Compliance 

Provider Contracts P.O. 

Box 6500 

Jefferson City, MO 65102-6500 

Physical Address: 

Missouri Medicaid Audit and Compliance Provider Contracts 

205 Jefferson St., 2nd Floor 

Jefferson City, MO 65101

*source: https://mmac.mo.gov/wp-content/uploads/sites/11/2019/05/CDS-Proposal-for-Contract-CDS-Orientation-Final.pdf*

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Economic Management: Maximizing Organizational Effectiveness (part 4 - The Podcast)

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The Rant - Economic Management: Maximizing Organizational Effectiveness ...

Economic Management: Maximizing Organizational Effectiveness (part 3 - The Podcast)

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The Rant - Economic Management: Maximizing Organizational Effectiveness ...

Leading Human Resources: An Analysis (part 24)

Planning and Implementing Change

by

Charles Lamson

Mark Twain once said, "The only person who likes change is a baby with a wet diaper!" Like it or not, in the dynamic society surrounding today's organizations, the question of whether change will occur is no longer relevant. Change will occur. It is no longer a choice. Instead, the issue is, How do managers and leaders cope with the inevitable barrage of changes that confront them daily in attempting to keep their organizations viable and current? Although change is a fact of life, if managers are to be effective, they can no longer be content to let change occur as it will. They must be able to develop strategies to plan, direct, and control change.

Resistance to change is contradictory to the manager's primary role as a leader. You will recall that in an earlier post, we defined leadership as influencing the behavior of others, individually and in groups. Influencing means moving from one behavior to another; in other words, change. American scholar, organizational consultant and author, Warren Bennis, defined leadership as the process of creating and implementing a vision. To be a leader, therefore, implies that you must learn to love change because it is intrinsic to the leadership process. Leaders must overcome their resistance to change and become change managers.

To be effective managers of change, leaders must have more than good diagnostic skills. Once they have analyzed the demands of their environment, they must be able to adapt their leadership style to fit these demands and develop the means to change some or all of the other situational variables.


General Framework for Understanding Change

Managers who are interested in implementing some change in their group or organization need a road map for change. The road map developed by Beckhard and Harris shown in Figure 1 is regarded as being among the best by prominent behavioral scientists such as Edgar Schein, professor emeritus at the Sloan School of Management, MIT. Furthermore, it is strongly supported by research. Let us take a journey using this road map to understand the change process.

Figure 1
A Map of the Change Process

Diagnosis  (Why Change?)

The first, and in some ways the most important, stage of any change effort is diagnosis. The central issue is identifying the need to change. Broadly defined, the skills of diagnosis involve techniques for asking the right questions, sensing the environment of the organization, establishing effective patterns of observation and data collection, and developing ways to process and interpret data. In diagnosing for change, managers should attempt to find out (a) what is actually happening now in a particular situation; (b) what is likely to be happening in the future if no change effort is made; (c) what would people ideally like to be happening in this situation; and (d) what are the blocks, or restraints, stopping movement from the actual to the ideal?



There are at least three steps in the diagnostic process: point of view, identification of problem(s), and analysis.

Point of View

Before beginning to diagnose in an organization, you should know through whose eyes you will be observing the situation---your own, those of your boss, your associates, your followers, an outside consultant, or others.

Ideally, to get the full picture you should look at the situation from the points of view of the people who will be affected by any changes. Reality, however, sometimes restricts such a broad perspective. At any rate, you should be clear about your frame of reference from the start.

Identification of Problem(s)

Any change effort begins with the identification of the problem(s). A problem in a situation exists when there is a discrepancy between what is actually happening (the real) and what you or someone who hired you (point of view) would like to be happening (the ideal). For example, in a given situation, there might be tremendous conflict among individuals in a work group. If this kind of conflict is not detrimental, there may be no problem. Until you can explain precisely what you would like to be occurring and unless that set of conditions is different from the current situation, no problem exists. On the other hand, if you would ideally like this work group to be harmonious and operative, then you have a problem---there is a discrepancy between the  real and the ideal. Change efforts involve attempting to reduce discrepancies between the real (actual) and the ideal. It should be pointed out that change efforts may not always involve attempting to move the real closer to the ideal. Sometimes, after diagnosis you might realize that your ideal is unrealistic and should be brought more in line with what is actually happening.

It is in problem identification that the concepts and theoretical frameworks presented in this analysis begin to come into play. For example, two important potential areas for discrepancy are, in Rensis Likert's terms, end-result variables and intervening variables.

In an examination of end-result variables, the question becomes: Is the organization, work group, or individual doing an effective job in what it was asked to do; that is, production, sales, teaching the three Rs and so on? Are short-term goals being accomplished? How does the long-term picture look? If performance is not what it should be, there is an obvious discrepancy.

If performance is a problem, you might want to look for discrepancies in the intervening variables, or condition of the human resources. For example, is there much turnover, absenteeism, or tardiness? How about grievances, accident rate, and such? The concepts you have been learning in this analysis can generate diagnostic questions for the change situation you are examining, such as:

• What leadership, decision-making, and problem-solving skills are available? What is the motivation, communication, commitment to objectives, and climate (morale)?
• What is the readiness level of the people involved? Are they willing and able to take significant responsibility for their own performance?
• What need level seems to be most important for people right now?
• What are the hygiene factors and motivators? Are people getting paid enough? What are the working conditions? Is job security an issue? How are interpersonal relations? Do people complain about the manager? Are people able to get recognition for their accomplishments? Is there much challenge in the work? Are there opportunities for growth and development? Are people given much responsibility?

Good theory is just organized common sense. Therefore, use the theories and questions presented here to help you sort out what is happening in your situation, what might need to be changed, and the degree of choice about whether to change.

Analysis---An Outgrowth of Problem Identification

Problem identification flows almost immediately into analysis. Once a discrepancy (problem) has been identified, the goal of analysis is to determine why the problem exists. The separation between problem identification and analysis is not always that clear, however, because identifying areas of discrepancy is often a part of analysis.

Once a discrepancy has been identified in the end-result variables or intervening variables, the most natural strategy is to begin to examine what Likert calls casual variables---the independent variables that can be altered or changed by the organization and its management, such as leadership or management style, organizational structure, and organizational objectives. In other words, can you identify what in the environment might have caused the discrepancy? Again, close examination of this analysis raises various questions. 

• What is the dominant leadership style being used? How does it fit with the readiness level of the people involved?
• What are the prevailing assumptions about human nature adhered to by management? How well do those assumptions match the capabilities and the potential of the people involved?
• Are people able to satisfy a variety of needs in this environment? How do the opportunities for need satisfaction compare with the high strength needs of the people involved?
• How do the expectations of the various situational variables compare with the leadership style being used by management?

*SOURCE: MANAGEMENT OF ORGANIZATIONAL BEHAVIOR: LEADING HUMAN RESOURCES, 8TH ED., 2001*

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Economic Management: Maximizing Organizational Effectiveness (part 2 - The Podcast)

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The Rant - Economic Management: Maximizing Organizational Effectiveness ...

How to Start a Home Care Business: The Proposal (part 9)

In-Home Services (IHS) and Consumer Directed Services (CDS) Proposal Information

by

Charles Lamson

Home and Community Based Services (HCBS) programs are intended to provide necessary assistance in meeting the unmet needs of seniors and adults with disabilities and enable the individuals to remain in the least restrictive environment. HCBS consists of two separate programs: in-home services (IHS) and consumer directed services (CDS). Separate proposals are required in order to be considered for the two programs.

The HCBS programs are operated by three state agencies:

• Missouri Department of Social Services (DSS), MO HealthNet Division (MHD). MHD is the single state Medicaid agency responsible for administering the Medicaid program, including HCBS programs.
• Missouri Department of Social Services, Missouri Medicaid Audit and Compliance Unit (MMAC). MMAC is responsible for determining potential business entities' eligibility to participate in HCBS programs as a Medicaid provider.
• Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). DSDS is responsible for assessing and authorizing HCBS services for eligible participants.

Purpose of Proposal

In order to be considered for Medicaid enrollment with MMAC, a proposal must be submitted to MMAC for consideration for a participation agreement ("contract"). A proposal is necessary for MMAC to evaluate the potential capability of business entities to provide HCBS in compliance with minimum regulatory program standards designed to ensure the health, safety and welfare of program participants.

Proposal Submission Requirements

All information listed in the appropriate Proposal for Contract must be submitted in order to be considered for a contract. The following preliminary requirements must be met or the proposal will be denied. The proposal must:

• Have Confirmation of Attendance CDS Orientation Training (CDS proposals only);
• Follow the current fiscal year Proposal for Contract;
• Be in the same order as the Proposal for Contract;
• Each policy and procedure must:
• Be on a separate sheet of paper;
• Include corresponding headings and numbering as the Proposal for Contract;
• Be signed (printed and signed name) by an authorized representative of the entity;
• Include the correct legal name of the entity throughout the proposal.
• Not use plastic page protectors or bind the proposal in any way (three-ring binder, brad, etc.)

Once a proposal is submitted to MMAC, it becomes the property of MMAC and will not be returned to the applying provider. Prior to mailing the proposal and/or any additional information requested, providers are encouraged to make a copy of the proposal for their records. Hand-delivered proposals must be left with the receptionist. No receipts will be provided unless a pre-prepared receipt is brought with the proposal. The receptionist will then date stamp the receipt.

Proposal Review and Approval Process

Upon receipt of a proposal, MMAC Provider Contracts:

• Will review the proposal to determine the applying provider's eligibility for a contract. MMAC will conduct any investigation necessary to verify or supplement the information contained within the proposal.
• If the proposal is incomplete or further information is needed from the applying provider to verify or supplement the proposal, MMAC will mail a written request for additional information.
• The applying provider is given thirty (30) days to submit the additional information. The proposal will be held pending receipt of the requested information. The written request will include Medicaid enrollment information that must be completed in order to process the MD enrollment later in the process. Failure to properly complete the enrollment information will delay the enrollment process.
• Failure to provide the additional information by the deadline noted in the written request will result in denial of the proposal. 
• If the written proposal is approved, a site visit will be scheduled and conducted by MMAC staff. The visit will include interviews with the applying provider's director, designated manager and RN supervisor. Staff must be knowledgeable of the requirements of the program.

• After the site visit, if a decision is made to offer a contract, the contract will be mailed to the applying provider for completion. The applying provider is never to assume the receipt of a contract for signature constitutes a binding contract until MMAC signs the contract.
• Upon return of the properly completed contract to MMAC Provider Contracts, MMAC will execute the contract. The applying provider will receive a copy of the fully executed contract and written notification of their SSBG/GR provider number. At this time, the Medicaid enrollment information that was completed during the proposal process will be forwarded to MMAC Provider Enrollment Unit for their review. If approved, MMAC Provider Enrollment Unit will notify the Provider by mail. MMAC Provider Enrollment Unit, at its discretion, may deny or limit the applying Provider's enrollment and participation in the Missouri Title XIX Medicaid program as outlined in 13 CSR 70-3.020.
• Upon receipt of the notification from MMAC Provider Enrollment Unit of approval, providers can begin providing services to participants when authorizations are received from DSDS.

After submission of a proposal, it is approximately six months before provider numbers are issued and services can be provided to DSDS participants. The amount of time required may be longer depending on the quality of the proposal submitted, the current workload of MMAC staff, and how quickly the applying provider responds to requests for additional information.

Provider Reimbursement Rates

Reimbursement rates are subject to and determined by the State Legislature on an annual basis. MHD publishes information on the reimbursement rates each year. MHD's Provider Bulletin Vol. 41 No. 2 dated July 5, 2018 contains the current maximum rate that will be paid for each service type provided. For example, the in-home services basic personal care current maximum rate is $4.53 per unit (or 15 minutes). While the rates listed in MHD's Provider Bulletin are the maximum rates that will be paid, the provider's usual and customary charge for each service provided should be billed.

Number of Participants

MMAC's approval of the business entity's proposal or subsequent Medicaid enrollment does not guarantee any particular volume of participants or that the services of a provider will be utilized by any state agency. Participants have the right to choose the care option, care setting and provider to deliver his/her care. When necessary to assist participants, questions will be answered by state agency staff using information obtained through the proposal and enrollment processes and subsequent contacts by state agencies with the provider.

Additional Assistance

MMAC is not aware of any organizations available to assist with the completion of a proposal or any grants available to defray the cost of starting a business.

The Missouri Business Portal includes information for starting a business in Missouri.

Questions

Should you require additional information or have questions regarding the proposal process, you must review the Frequently Asked Questions (FAQs) prior to contacting MMAC. If you still have questions, you must contact MMAC Provider Contracts by email at  mmac.ihscontracts@dss.mo.gov. Submitting questions through email will provide a written record of MMAC Provider Contracts' response. Your email must include the name of your agency.

Consumer Directed Services Packet

• CDS General Information
• CDS Proposal for Contract
• CDS Assurances
• Information Sheet: HCBS Setting Requirements

*SOURCE: https://mmac.mo.gov/providers/provider-enrollment/home-and-community-based-services/contract-proposal-information/*

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