Leadership Tips: Preparing for a Stressful Budget Season

Budget season and business planning are often stressful for palliative care leaders. And this is an unusual year; the COVID-19 pandemic has changed care patterns, and disrupted “normal” revenue flows for health systems and other health organizations. Hospitals are expected to face significant financial shortfalls in 2021 and 2022.

This said, the pandemic has also expanded palliative care visibility and opportunities through engagement with new clinical partners, care settings, and roles for the interdisciplinary team (IDT). Palliative care leaders can use this budget season to strengthen their current position in the organization and “plan forward” for the highest impact aligned with organizational needs... making this a very good time to think strategically.

During the first surge of COVID-19, we spoke with Lynn Spragens, MBA, who shared actionable tips for palliative care leaders during the pandemic, with a focus on budget planning. During our conversation, available on-demand (and below), we learned how palliative care leaders can proactively address complex staffing and budget planning, as health care organizations and practices grapple with the multiple and often delayed impacts of COVID-19.

In this blog post, we share key takeaways from the first conversation and updates that Lynn recently provided, a year into the pandemic. We hope that her guidance helps ease the stress of this budget season and encourages you to take practical, feasible steps to plan forward.

The dialogue below has been edited and synthesized for easier reading, and content has been approved by Lynn.

Lynn Spragens (LS): I am a consultant to CAPC, with thirty years of experience in health care and business operations. I have worked closely with CAPC since its start, to help think through challenges in the field, and bring practical approaches to align with goals and funding (for improved patient care), with health system leadership priorities.

LS: Yes, absolutely. This is important because the COVID crisis creates significant disruption to current health system business revenue, uncertainty about future operations, and complicates revenue forecasting. Naturally, this may increase risk aversion and drive more conservative financial management by finance staff and leadership. Therefore, it’s important to be proactive and flexible, and show respect for the seriousness of their dilemma. It is their job to show stewardship and ensure enterprise-wide financial health, so that the care of patients can continue. Here are some tips that I have been sharing with palliative care leaders:

1) Don’t be surprised by financial constraints
This is your leaders’ job, and it’s not a fun one. Not only are they juggling a lot, but there’s also uncertainty. Be kind and ask what they are most worried about, what goals they need to meet, and what they need from you. Having this information will help you plan and respond constructively.

2) Learn from your team
Dig deep into your team members’ joys and fears, collect stories and examples, and identify surprise successes and new collaborators that have appeared during the COVID work. Think through how this can help streamline or improve your work. Identify gaps that frustrate your team. Are there new collaborators who can help you get the work done? Brainstorm about appropriate ways to continue to use telehealth to expand capacity for follow-up and contact with patients. Including your team in the process will bring forward important insights, and make it less intimidating.

3) Develop Options
Build out several viable options for the best use of available resources, and be able to connect the dots between effort and impact. Present options to your leadership; let them help you decide where your scarce resource is best applied. For example, your leadership may be most concerned about ICU crowding, wanting you focus there. Find out what their priorities are and ask if you should re-allocate your efforts to align with them. Choice has a way of changing the conversation constructively. This works well, whether your program is growing, stable, or being pressured to pull back. (See Part 2, below, for more on this topic.)

4) Be proactive
The pandemic may end up presenting a strategic opportunity to jump over old hurdles. Because of the crisis, some leaders have learned to make quick decisions and do things that don't always go through the traditional hoops, committees, or processes.

So, consider things you've thought about before, but were not able to move forward, due to process barriers. Think about the needs and the timing, and whether this is an opportunity to jump forward with things that matter. This could mean providing services in a new setting, expanding the training of others, using your team members differently, working with new collaborators, or an opportunity to reach out successfully for philanthropic support. Think outside the box. What do you want to be able to do differently in the future?

LS: Expect this to be an unusual budget year. Roll with it, and have some humor and forgiveness. Given the essential nature of palliative care, be ready for opportunities to break through, and be patient with the process and the people. Be supportive and transparent with your team. And please visit capc.org for additional resources, such as Virtual Office Hours, where you can talk with colleagues and CAPC faculty on topics like this one.

Given the state of the pandemic, we asked Lynn if she had any updates since our last conversation.

LS: Everything from our initial conversation is still relevant, but there has also been some positive activity on the Part B billing-front. In 2020, the Centers for Medicare & Medicaid Services (CMS) expanded and clarified the rules and reimbursement for telehealth visits, making it more feasible to deliver an effective mix of face-to-face and virtual care for patients over time. It has also made more appropriate (and billable) use of the interdisciplinary team.

Also, we are hearing many positive stories from palliative care leaders, who have experienced breakthroughs with their programs during the pandemic, as colleagues sought out palliative care expertise to help their patients, families, and staff.

LS: The innovations and exceptions enabling virtual care, and expanding billable providers, are likely to last for at least the rest of this year; and they can dramatically improve your ability to serve patients in need. These adjustments are especially important for home-based palliative care teams. It is uncertain whether these changes will be permanent, but understanding how this can help you deliver the care your patients need is important. And your efforts to maximize these opportunities demonstrates effective stewardship to leadership.

This echoes the messages I shared previously: think creatively about how to use your team, look at how you're using your time, and think about the options available to you.

Palliative care leaders should check with the billing experts from their respective organizations, of course. I also encourage you to review CAPC’s billing resources, which includes a summary of the CMS updates, and other palliative care billing resources that may be helpful to your program. Additionally, this new budgeting tool and companion guide can help community based-palliative care programs with their operating budget.

LS: A positive has been the increased receptivity to home-based and virtual care, as people have been hesitant to go to the office, as well as the hospital. I believe this will likely stick, after the pandemic. Besides patients, hospitals, health systems, payers, and public health officials all currently have an interest in being able to flexibly accommodate service delivery. This is aligned with community-based palliative care initiatives, and with better coordinated work between inpatient and community-based teams.

LS: The pandemic has allowed for palliative care teams to work closely with many new colleagues, develop new relationships, and break through levels of leadership. There has been new access to senior leadership; palliative care leaders can use this to be as creative as possible.

It goes back to the needs assessment. You need to figure out what they care about and come back with options which demonstrate how you can help. And it’s more important than ever to deliver on what you say. It’s important to ask questions to learn what's possible and what people most need. Then create options that allow you to solve those problems.

Uncertainty and disruption are actually your friends if you can be patient and creative. We need everyone to take a deep breath and to play this role well—listen, have compassion for leadership, and be a problem solver.

LS: Go to leadership with options, or what other people may refer to as ‘solutions’. (I like to use ‘options’ as there’s more than one way to solve a problem, and “options” implies collaborative solutions, vs. “I have the answer for you”.) If your leaders share the problem of deciding where your resources go when you can’t be everywhere, they will understand the real tradeoffs and have a bigger stake in your impact. You’ll be much more successful getting to ‘yes’, when you:

1) Think about positioning
For example: “There are three different things we could do to address that issue…”

2) Lay out the options
For example: “We could focus on X, Y, or Z to improve this problem.”

3) Describe the “future state” and your goals.
For example: “This initiative will allow us to affect _____. We’ve talked with others and looked at the data, and _____.”

Often, leadership will pick at least one of the options that you present as long as it is aligned with their biggest priorities. And you’ll be in a better position to ask for what you need, in a creative way, as they’ll be invested in the option. At the end of the day, if you present options skillfully, by linking up problems and actionable plans with funding needs, you will often receive leadership support for some action.

LS: Know your business, including what your team is doing. Seek mentoring and guidance on these decisions from your leaders. Be reasonably confident, and sincerely curious and interested in what your leaders need. Be creative about matching interests and needs with things that are realistic for you and your team to solve. Be thoughtful about what you put forward, and understand what you would need in order to realistically, reliably solve problems.

LS: Regardless of when your organization's budget year starts, they are still planning. Everyone is dealing with uncertainty. Be proactive, creative, and collaborative. Identify their time horizon (maybe new funds aren’t available until mid-year?). Connect the dots between opportunities to improve care, and the resources you need. Your proposals should be flexible and say: “based on what you’ve indicated is a key priority, here's a problem we're trying to solve, and here are the ways we could solve it.” Remember that new or different impact may be valued more than current work.