“Twice the life at half the cost”

By: Connie Nelson

How likely is it that a 150-year-old organization comprised of Minnesota Lutherans would be a hotbed of innovation?  It turns out pretty darn likely!  In 2011, Lutheran Social Service commissioned a complete redesign of services for people with disabilities.  This design has dramatically changed how the needs – and lives – of Minnesotans with disabilities are viewed and realized.  Following is a retrospective of that design work.

In 2011, Lutheran Social Service of Minnesota (LSS) asked Re:DESIGN practitioners [i] to look at the entire system of services and supports for people with disabilities across Minnesota.  This wasn’t an easy decision to make.   As Jodi Harpstead, now CEO of LSS, recalls: “(Former) CEO Mark Peterson and I were driving home from Camp Knutson in northern Minnesota, a nature camp that exists to nurture the well-being of children with special needs.  On that long drive, we were discussing the state’s current budget deficit and were concerned that people and children with disabilities would be particularly vulnerable to budget cuts.  We were part of a provider coalition that worked together to ask for rate increases, but we didn’t think that more lobbying provided enough of a path out of this fix.  We wondered about asking for a fresh look at all the services.  We had never done something like this before.  We were only one actor in the marketplace, and we knew that some of our provider peers would think we were stepping out of bounds.  However, we decided it was too important not to act.” 

At this moment, Lutheran Social Service, while the largest not-for-profit in Minnesota overall, served only ten percent of this market.  It is rare for a provider with a small piece of the pie to step back and reflect on how an overall system works.  It is even more rare for an organization to do so without placing themselves at the center of the inquiry.  LSS did just that.  They approached Re:DESIGN practitioners and asked that we put real people with disabilities at the center – or heart – of the work. 

All of us started by understanding and defining the people to be benefitted.  It was decided to design for people across the whole state and across all ages.  That meant that the design had to benefit: a person born in the 1950s who had may have been institutionalized and then “de-institutionalized” in the 1990s; a person born in the 1980s, raised at home and mainstreamed all her life; up to a person born yesterday.   

Through the redesign approach, LSS developed the My Life, My Choices Design, a design that affords each of these people more independence and more choices – including choices that involve risk and trade-offs – while simplifying the expensive, often over-protective system.    

Before I describe the actual design, l would like to mention a tenet of Re:DESIGN.  Systems produce the results they do by design.  Often unspoken – and sometimes forgotten – assumptions underlie them.  It is important in redesign to surface and name those underlying assumptions.  Doing so with two assumptions was especially important here -

An early “Aha” occurred when one designer observed, “The system seems to equate people who are disabled with unable.”  Just consider the words that our laws used: Wards. Vulnerable adults. Guardians.  Designers realized that fear “for” people with disabilities removed many decisions from them they might actually make.

Instead, the designers explored:  What if the system instead assumed that people with disabilities, were differently abled?

Second, the system was aimed squarely at realizing the outcome of Safety.  Rules ruled the day.  Extensive regulations (down to the type of sunscreen to apply) and reporting requirements tried to drive risk to zero.  Not only is zero-risk tolerance extremely expensive, it can also hamper a day at the beach – literally.  One interviewee said, “We are afraid to take them to the beach for fear of anyone getting a sunburn.  People with disabilities are so protected, it’s hard for them to live a life!”

The designers explored:  What if the desired outcome moved from Life-Safety to Life-Quality?

As the leaders commissioning the design work, LSS readily agreed that these new assumptions and this outcome should guide the design.  The design that resulted painted a new “to-be” future for Minnesotans with disabilities.  Elements include: 

Instead of categorical funds from multiple governmental sources – each of which must be administered and accounted for separately, the design envisioned bundled monies for each person.  Unfunded mandates would be replaced by un-mandated funds.  And, there was an expectation that public funds could and would be supplemented with the person’s own earnings.

Instead of the dollars flowing through to 87 counties and multiple providers via “cases and contracts,” the design envisioned these dollars flowing to the individual’s virtual or real wallet - from which she or he, along with a trusted partner, could purchase services needed, and no more.

Instead of the person with disabilities being served with little say, the design envisioned her purchasing the community resources that work best for her.  That is, the marketplace would have to respond to her, and her needs – not those of the county or state. 

This Design Visual illustrated the high-level “to-be” future:

These contrasting visuals were used with the Legislature, and multiple stakeholder groups.  And they got it right away.  As one advocate said, “We have been working together for several years.  Finally, someone has captured a compelling vision, the direction we all want to achieve.” 

The design won a MN 2011 Innovation Award, supportive legislative language passed both house of the Legislature unanimously, and it was implemented immediately.   Well, at least the first two clauses in that sentence are true. 

Five Years Later: 2016

Having a design in hand and having that design fully implemented are two different things.  Five years have passed since the design was commissioned.  In October 2016, I met with Jodi Harpstead, CEO of Lutheran Social Service to ask: “What has happened - to Lutheran Social Service, to the people you serve - since the design work?”

“Good News!”

The My Life/ My Choices design has led to –

1.    Person-Centered “Best Life” Service Design and Delivery – one person at a time

Lutheran Social Service of Minnesota immediately began to work with each of their customers, offering them lower cost/more independence options. They were successful.  But, there was a problem: neither they nor their customer realized any “share” in the savings that were realized. 

They went about rectifying that.  And, in 2015, the MN Legislature granted Lutheran Social Service, along with six partners, permission to form the only Accountable Care Organization (ACO) in the nation to focus solely on people with disabilities. Called Altair for “brightest star”, it is also the only ACO that is led from the social services side instead of the medical (health care) side. 

This was the mechanism they needed to get rewarded for helping people make less restrictive/less cost health, housing and social service decisions.  Along with Bluestone Physician Group, LSS and their other social service partners are “getting really smart about Minnesotans with disabilities – fast.”

Evidence of Design Success –

• Altair receives incentive payments based their success in helping customers design and use less restrictive/ less cost options. To date, they have received $900,000 in incentives and innovation grants --- more than any other ACO in MN!

• Robert Wood Johnson auditors came to LSS in Sept 2016 to assess Altair. At the conclusion of their visit, they were giddy with what they had seen. They said that they work every day to get hospitals and health care providers to look at – and care for - the whole person. Here, Altair approaches everything from the point of view of a Minnesotan with disabilities who occasionally goes to the doctor or the hospital. They said, “Everywhere else they call them patients. You call them people.”

• A changed life. “One woman whose parents moved her into a group home to be “safe” didn’t want to be there. We helped her move to her own place and get a job. She fell in love and got married. Now she lives with her husband, and has gone from a $67,000 public budget to zero.”

2.    “One Good Design led to the Next.” – Jodi Harpstead

In 2015, Jodi Harpstead and LSS decided they needed additional strategies to work with people with disabilities who need intensive services.  These are Minnesotans who require around the clock care and/or one or more fulltime caregivers.  The resulting Intensive Services Design [ii] has helped LSS assist people with intensive developmental disabilities achieve a life more of their own choosing. 

Evidence of Design Success –

• A changed life. Recently, a man who was living at Anoka State Hospital costing $1500/day requested that LSS assume his services. In the beginning, he required two caregivers/ 24 hours a day - or $1500/day - from them too. Then, as he was assisted in getting his own place, he relaxed and even found a job. Currently, LSS provides one caregiver 24 hours/day. This means his services now cost $750/day. Most importantly, he is living in the community, with his own job. Jodi concluded this story, “He has twice the life at half the cost.”

• Jodi also said: “From these two designs, we are well positioned to contribute to the State of MN’s Olmstead and 2020 Plans which seek to have every single person with disabilities living with the most independence possible.”

3.    Measurable Results

Since 2004, LSS has been shifting toward “consumer-directed services.”  My Life My Choices did not start that shift, but it has accelerated it.  In FY 2016 alone, LSS offered over 150 new people self-designed options.  

Bottom line, here are the numbers.  Between 2004 and 2015:

• A Doubling of Those Served. LSS is now serving twice the number of Minnesotans with disabilities. In 2004, they served approximately 1000 people. Today, they serve 2000.

• Twice as Many Enjoy Consumer-Directed Services. In 2004, 37% of people served by LSS had consumer-directed services. In 2015, 65% do!

• At Lower Per Person Costs. The average cost per person served has dropped from $42,000/person to $35,000 per person.

Jodi Harpstead concluded: “When I look at the Board Outcomes I work toward, the outcomes realized through My Life My Choices far outstrip what we could have done without it.”

“Hardships”

The implementation path hasn’t all been easy –

Early “bumps” along the road.  Remember when I said that the My Life/My Choices language was passed unanimously by both houses of the Legislature?  Unfortunately, the language was included inside an omnibus bill that, for other reasons, was vetoed by the Governor.  When Jodi Harpstead tried to meet with the Commissioner of Human Services who was determining which sections of the Omnibus Bill were critical to pass in the subsequent special session, Jodi was informed that the Commissioner didn’t meet with individual providers. The My Life My Choices language was not included in the bill passed. LSS had to wait another year. 

But, the story doesn’t end there.  Jodi did eventually meet with the Commissioner – who, a reformer in her own right, loved the work.  Together, the two of them have testified at the Federal level - a first for a Commissioner and provider to appear jointly.  The design has informed the State’s 2020 strategic plan.  And, believing in this work so much, after leaving her commissioner position, she now serves as a Board Member for Lutheran Social Service of Minnesota.

Separate County Administrations as a Hindrance.  LSS would like to offer “host homes” as an option to many more people with disabilities – especially those currently living in state or local facilities.  Host homes is one housing choice that resulted from My Life/ My Choices.  It enables people with disabilities to live with a family (akin to adult foster care) -- in community and with much more freedom and choice in the supports they need.   People willing to offer host homes has not been the problem.  Neither have we had a lack of those interested in living in a host home.  The host home option has been popular – and today, LSS has 41 adults in host homes. But, LSS has also run smack dab into the fact that MN has 87 different county administrations.  After 5 years, only 12 out of 87 counties have allowed this option for people.  Hennepin County – Minnesota’s most populous – has just approved it after 5 years of trying.  Jodi sighs, “You know what.  The stories are marvelous – and we won’t stop trying.”

Suddenly, Additional Oversight.  Being an innovator is a lonely place sometimes.  Possibly because of their success in receiving new incentive monies, a few legislators have asked the Legislative Auditor to audit LSS.   So, rather than getting additional help to make these transition years happen, suddenly the status quo goes unexamined while these new approaches get extra scrutiny.  However, Jodi remains hopeful that the Legislative Audit report will contain praise of their innovations.  (As of this date, no draft or final report is available.)  Jodi knows from her work with other Lutheran Social Service leaders across the nation that Minnesota is in the forefront of needed changes.

Some Design Aspects Have a Ways to Go.   I asked Jodi the status of one of my favorite aspects of My Life My Choices – the individual budgets and choice in how to spend that money.  Jodi answered: “Has MN gotten to a place where we have dollars or individual budgets for each person?  No, but that philosophy has guided our every step.  And, as far as LSS is concerned, we would love to get to the future where a person can share in and bank some of his or her own savings, based on the choices made.”  

Jodi concluded, “Everything we’ve done has been guided philosophically by the My Life My Choices Design.” 

Parting Thoughts

While My Life My Choices was her first Design initiative, CEO Jodi Harpstead has subsequently commissioned four additional Designs, all supported by practitioners from Re:DESIGN.  I asked Jodi to think back to her earliest encounters with Designing as an approach and describe what it was like.  Jodi said:

“MLMC was my first exposure to design thinking.  I thought it so much richer than traditional strategic planning… you know: setting strategies, objectives and tactics.  Designing uses your whole brain.  I loved the early scan:  What’s happening elsewhere?  What are stakeholders thinking? I loved the assumptions being voiced and reworked.  And, those incredible illustrations of today and tomorrow…  for the first time we could see how the whole system looks, not just our services.  They also helped so much with our peers: “If you can picture it, people understand.  I now have been known to say around LSS, “We don’t only plan.  We design!”

As for me, what is so encouraging about this story is that Designing for the Common Good is not simply about adding novelty to services. Its aim is higher - to achieve more results from public dollars invested.  It is about creating value for people.  It is about improving lives.  Then, and only then, have we truly been successful with Design.

The credo of Lutheran Social Service of Minnesota is: “… because changing lives can’t wait.”  Thank you, Jodi Harpstead and Mark Peterson for your continued, dynamic leadership in helping people live “twice the life at half the cost.”