By Beth Blair, Traci Wilson, Marisa Scala-Foley, USAging
More than 600 Area Agencies on Aging (AAAs) across the country support older adults to live in the community with dignity and independence for as long as possible. AAAs — which may be nonprofit organizations, parts of councils of government or regional planning and development agencies, or parts of city or county government, and may have different names — share a mission to develop, coordinate, and deliver services that address the health-related social needs of older adults in their communities. To further address social needs, a growing number of AAAs are contracting with health care entities to provide care coordination, evidence-based programming, nutrition, and other services. These partnerships can have substantial impacts on health and cost outcomes.
Past research showed that counties where AAAs had partnered with more types of organizations had lower hospital readmission rates among older adults than those with fewer partner types and that certain types of AAA-health care partnerships offered the potential to reduce Medicare spending and nursing home use at the county level. As evidence of the value of these partnerships grows, stakeholders continue to encourage AAAs and other community-based organizations (CBOs) to enter into contracts with health care entities. However, some AAAs may have certain characteristics and strategies that facilitate their work with health care organizations. New research provides insight into how these AAAs build and maintain these health-related partnerships.
A research team from the Yale School of Public Health, the University of California Berkeley School of Public Health, Scripps Gerontology Center of Excellence at Miami University, and USAging conducted a study to learn more about the strategies that AAAs employ when developing partnerships with health care. Based on previous research described above, they targeted AAAs with a high number of formal health care partnership types and a low proportion of county nursing home residents with low care needs. The comparison group was made up of AAAs with the fewest health care partnerships and highest proportion of nursing home residents with low care needs. Health care partnerships data came from the 2019 National Survey of Area Agencies on Aging. Responding AAAs selected which types of health care entities the agency had a formal partnership with from a list of ten options. The AAAs with high levels of health care partnerships reported formal partnerships with four to eight of the health care entity types on the list, while a comparison group had one or fewer formal health care partner types. The sample was diverse in geography, area served, agency size and organizational structure. The team conducted 130 in-depth interviews with staff at AAAs and their health care partner organizations. Three common characteristics emerged that describe the organizational culture of AAAs with a high number of health care partners:
- Attention to external environments;
- Openness to innovation and change; and
- Risk taking to learn, improve, and grow.
1. Attention to External Environments
AAAs with high levels of health care partnerships paid particular attention to their environment by monitoring demographic and regulatory trends and identifying gaps that they could address with their services. These AAAs also actively sought to understand their partners’ terminology, goals, and ways of working. This allowed the AAAs to identify partner needs and how they could meet them, market their services using terminology that resonated with the partner, and then work closely with them as the partnership developed. As one AAA senior program director stated:
“What we're addressing are the social determinants of health. That's really our expertise. That's what we've been doing since the 70s…there's been a slow transition where health care organizations and insurance companies are starting to see the value of addressing social determinants of health. We've been learning more and being able to show more outcomes and speak the language of health care because it is very different. We've been doing value propositioning.”
These AAAs understood the need to identify opportunities for partnership in their communities, and to market their services in a way that would be meaningful for their health partner.
2. Openness to Innovation and Change
Another characteristic that the researchers identified in AAAs with high levels of health care partnerships was their culture of openness to innovation and change. AAAs described activities to adapt roles, programs, and operations to increase their readiness for contracting and to ensure that their staff had the appropriate business development skills to navigate partnerships — such as negotiating and being able to articulate the value of AAA services. Several participants identified the need to develop capacity and ensure culture change throughout the organization and to “bring your team along.” In addition, AAA staff described the need to try new approaches and aim for quality improvement. According to one director of community resources:
“We can’t just keep doing the same thing over and over again. Something that made sense five years ago doesn’t necessarily make sense today. Not necessarily throwing everything out, but what elements can we keep and where do we need to tweak?”
The characteristic of agility and openness to innovation and change also related to their ability to take risks and move in unfamiliar directions.
3. Risk Taking to Learn, Improve, and Grow
AAAs with high levels of health care partnerships were open to innovation and change, but also willing to jump in and learn as the partnership developed. The researchers found that this willingness and ability to take risks and be comfortable with uncertainty was a strong theme. As one AAA manager of home and community-based services intake stated:
“We've got a new director who is very, very open to thinking in a different way. [She] is just a great global thinker…she gave us the freedom to say, ‘Let's try some pilot stuff. If it doesn't work, it doesn't work, but we'll still learn something from it.’”
Similarly, a AAA assistant director noted:
“We were in a one-year program learning a tremendous amount about how health care systems work and how we can interface…if we'd known this before we jumped in, we would be better negotiators…But that isn't how it works. You're in it. You're doing and then you're learning and you're trying to mature yourself all at the same time.”
In this way, AAAs with high levels of health care partnerships were willing to learn through experience to better position the organization for contracting later.
Learning from AAAs with High Levels of Health Care Partnerships
Through this study, researchers identified features of organizational culture that are common among AAAs with successful health care partnerships. These AAAs are focused on the potential needs of partners and aware of opportunities in their environments. They are able to innovate and change in order to take advantage of these opportunities, and to adapt their internal operations and culture to implement new initiatives. Lastly, they are willing to take calculated risks to pursue their goals.
A growing proportion of CBOs are contracting with health care entities, but contracting work is challenging. AAAs and other CBOs can strengthen their internal capacity for this work by accessing the resources of the Aging and Disability Business Institute. The experience of AAAs across the country during the COVID-19 pandemic also indicates how cultural characteristics — such as openness to change and risk-taking — can be learned. AAAs rapidly adopted innovative service delivery strategies and formed new partnerships to respond to the pandemic and the need to keep their clients safe.
Collecting and synthesizing the common strategies of AAAs that have successfully contracted with health care organizations can help other AAAs and CBOs in their efforts to serve older adults and people with disabilities through contracts with health care entities.
These findings are also useful for leadership at health care provider and payer organizations looking for CBOs to contract with to meet social and community living needs. Learning about AAAs in their regions that are open to jumping into a new initiative could begin a successful partnership to support older adults and people with disabilities in the community.