Cynthia Hundorfean, EMBA

The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

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Thank you to our wonderful participants this afternoon in the HCT Consulting Group Healthcare Transformation Executive Roundtable. Brian D. Washburn, DHA, MHA, FACHE, FACMPE, CHFP, PMP Chris Saxman Elizabeth Crawford Restat Elya Prystowsky, MS, PhD Mark Korth. I was encouraged by several insights from this amazing group: 👉 #Transformation - we know it when we see it! 👉 #Valuebasedcare - we know it when we don't! 👉 #Valuebasedcare means different things to #patients and #providers but we should not lose sight that like or not, we have to play by the language and definitions being proposed by the Centers for Medicare & Medicaid Services 👉 #Transformation towards #VBC should be keeping healthcare simple, local and well-coordinated - what 99% of people are trying to do today. Organizing to stop the despicable 1% is adding 30% of costs to everyone - especially #ruralhealth 👉 #EMR Transformation has put some hospitals out of business and in some communities, when the hospital closes, the whole community shuts down 👉 #Transformation this group sees on the horizon includes demand for change only intensifying, doing more with fewer providers, addressing #documentation challenges, #AI should focus on removing the hassle of the little things 👉 MAJOR RISK AHEAD - Will #transformation defined by CMS + #BigTech lead to a loss of simplifying the provider-patient experience? Will documentation to meet #VBC demands only escalate due to the 'potential' of what technology offers? And therefore, will health disparities only expand due to the inability of #ruralhealth to keep up? Ultimately - will we eventually have to unwind many of the current technology investments to one day return to a simpler provider-to-patient connection? Thanks again to our amazing participants. DM me if you'd like to be on our roster to participate in the next one!

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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On October 8th, U.S. News & World Report released its annual rankings of Children's Hospitals, called "Best Children's Hospitals". It is a 174-page report describing the methodology and data tables which I scanned through. Appendix C-10 has the data on Pediatric Pulmonology which I took a deep dive into. In the attached carousel, I have recreated two datasets that matter. If I were to shop around for a hospital for my care, what really matters to me is the outcome data for a particular condition I am seeking care for and not the reputation score. However what separates the top-ranked "Best Children's Hospitals" is their reputation scores, not the outcome scores for selected conditions as in asthma here. It's a different matter whether the outcome scores used in the rankings are good measures. We will discuss them in another post. What are your thoughts? Feel free to like, share, and comment. #healthcare #hospitals #physician

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It's wild to think in 2024 we're FIRST seeing the DOJ accuse telemedicine conglomerates of criminal drug distribution. How long have we known about these practices in brick and mortar care...? Answer: decades! Take it from someone who prescribed stimulants and other psychotropics to kids over the years - painstakingly measuring and documenting the need and impact - these appalling abuses by Done and Cerebral mean we need more calls for thoughtful pause when it comes to working with startups. Particularly about funding's role - my favorite topic! 🤑 How did we end up with venture capital and PE financing in healthcare that risk the safety of kids in the name of exorbitant returns? Not that all VC or PE dollars are bad, of course, but they're certainly key drivers who shouldn't be in that seat. Did we underestimate these funders as 'barbarians at the gate', much like the pharma reps of the 90's and early 2000's heyday? Have we not learned from Purdue Pharma's aggressive and deadly Oxoycontin marketing? Purdue pleaded guilty to criminal charges and paid $600 million in fines in 2007. Or TAP Pharmaceutical Products's Lupron kickback scheme for the prostate cancer drug? TAP also pleaded guilty to criminal charges and paid $875 million in fines in 2001. Or Pfizer marketing Neurontin, an anti-seizure drug, for off-label uses, such as treating pain and bipolar disorder, even though the drug was not approved for these purposes, and paying physicians kickbacks. In 2004, Pfizer pleaded guilty to criminal charges and paid $430 million in fines. Cerebral and Done's playbooks were practically the same thing, just with a modern mid-pandemic, low-regulatory scrutiny, digital-platform twist. Will appropriate regulation ever outpace American venture greed? Is it even possible to ensure patient safety AHEAD of tragedies driven by the intersection of innovation and venture funding? If you're keeping score, healthcare regulatory reactivity: 1 million. Healthcare ounces of smartly preventive policy: 3. Blech. 😖 When will we finally own that prevention in-house? #healthcare #overdoseprevention #suicideprevention

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Exciting times at 4C Digital Health! Wilmington, Delaware - 4C Digital Health (4C), the preeminent organization delivering independent financial oversight and control solutions for self-funded employee health plans, recently announced the strategic expansion of its services into the Commonwealth of Kentucky. In late 2023, 4C successfully competed for an initial award issued by Kentucky’s Department of Employee Insurance, and Kentucky has since extended the initial contract to allow 4C to continue its important work on behalf of the Commonwealth, its employees, and its taxpayers. The Kentucky Employee Health Plan (KEHP) serves more than 288,000 members, which amounts to 1 in 16 Kentuckians. In addition, KEHP spends over $1.8 billion dollars in total healthcare benefits on behalf of its members per year and covers over 8.2 million claims per year. KEHP objectives include “improving employee health and well-being” and “providing state-of-the-art benefits while maintaining reasonable premiums.” Recognizing its important fiduciary responsibilities to its employees and its state health plan, the Commonwealth of Kentucky enacted Senate Bill 42 (2023) introduced by Senator Stephen Meredith for the purpose of ensuring that critical health plan dollars are being spent properly on behalf of state employees. The legislation requires that 4C analyze 100% of medical claims submitted for payment to KEHP; identify erroneous overpayments; and identify inappropriate or erroneous fees imposed by KEHP’s third-party administrator. Ron Templeton CEO of 4C Digital Health stated: “4C Digital Health is grateful to the Commonwealth of Kentucky for recognizing the fiduciary responsibility that state and local governments have to their employee health plans and for the opportunity to provide our services in support of this mission. We appreciate Kentucky’s goal of using 4C’s expertise and innovative solutions to improve healthcare outcomes and reduce healthcare costs for the Commonwealth, its employees, and its taxpayers.” About 4C Digital Health: 4C Digital Health (https://lnkd.in/eB-fJg4X) is a healthcare data analytics company that was founded for the purpose of developing a disruptive technology targeted at bringing transparency and honesty to the healthcare marketplace.

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What does health insurance do? The conversation in the attached screenshot sums it up. We have a distorted market in healthcare. For drugs, there is a middleman called PBM between the insurance and the drug companies. The PBM negotiates a higher rate than the cash price - usually 2x or 3x and then receives an under the table rebate from the drug company. It passes of portion of this rebate to the insurer. The end effect is that the bottom price for the consumer is increased. The consumer believes that their insurance saved them a lot of money. #healthcare

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Suggestions on Choosing the Right Healthcare Proxy Choosing the right healthcare proxy is one of the most critical decisions you can make for your health and well-being. A healthcare proxy is someone who will make medical decisions on your behalf if you are unable to do so yourself. At Patient Advocates of Southwest FL, we understand the importance of this role. Based on first-hand and the experiences of more than a few clients, I’m here to share some key advice to help you make the best choice: 1.      Trust is Paramount: Select someone who understands your healthcare preferences and whom you trust implicitly to make decisions that reflect your wishes, not their own. 2.     Availability Matters: Your proxy should be generally available and can be present when needed, especially in urgent situations. Confirm they are willing and able to commit to this responsibility. 3.     Knowledge of Medical Matters: While they don't need to be a medical expert, choosing someone with a basic understanding of healthcare or who is willing to learn about your specific health conditions can be immensely helpful. 4.     Communication Skills: Your healthcare proxy should be a strong communicator. They will need to discuss your care with medical professionals and potentially other family members, advocating effectively on your behalf. 5.     Legally Prepared: Ensure that your healthcare proxy is legally documented. It’s always wise to consult with a legal professional to verify all paperwork accurately reflects your choices and is binding. Choosing the right healthcare proxy is about more than just fulfilling a role; it’s about ensuring that your healthcare decisions are in trusted hands. Your health deserves the utmost care and preparation. #HealthcareProxy #PatientAdvocacy #MedicalDecisions #HealthcarePlanning"

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Home healthcare providers face increasing pressure from Medicare rate cuts and rising operational costs and unfortunately, the nurses and care team often feel the brunt of this pressure. "The Centers for Medicare & Medicaid Services (CMS) has proposed cuts to home health payments three years in a row. Though its last two final payment rules have not been as harsh as its proposals, they have still come with permanent cuts to payments. Providers have multiple gripes with these cuts. The first is over the payment methodology that CMS applies, which most providers and advocates strongly disagree with. The second is the rising costs that home health agencies have recently faced. While CMS is cutting home health payment in traditional Medicare, the cost of providing services has skyrocketed – namely due to the cost of labor." If you're a home healthcare provider trying to do more with less while also wanting to support your clinical team, please reach out. We're happy to help! #coordinista #HomeHealthCare #Efficiency #ClinicalOptimization #HealthcareInnovation #nurses #fieldcaredelivery https://lnkd.in/gS5z3-Jj

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Very interesting article. It compares hospital and health plan consolidation in specific markets. Indiana is a market that is deemed a high cost market (7th highest in nation for hospital costs) because of hospital consolidation per studies, yet when you look at the market, plans have more leverage as the top 3 represent 91% of the large group market. A few thoughts: 1) you can look at number of hospitals, but it would be better to compare commercial spend for these systems as I would imagine a lot higher than the counts indicate. Some hospitals may have a higher proportion of governmental business and that needs to be considered. 2) Based on plan leverage, one would think plans would say no to continued commercial price increases. It's important though that employers support plans in these discussions. I have seen many times over the years that employers want access above everything else, which means the plan has little leverage with the hospital to take hard line stands or risk losing large national employers who will just switch to another plan creating a vicious cycle of continued cost increases. 3) Under this environment, there is little incentive to move to VBC like arrangements vs. fee for service. 7. For example, in Indiana, the systems with the largest share of total hospitals are St. Louis-based Ascension (13.9%), Indianapolis-based IU Health (11.3%), Mishawaka-based Franciscan Health (8.7%) and Franklin, Tenn.-based Community Health Systems (8.7%). These four systems own 42.6% of all the hospitals in Indiana combined 8. On the other hand, the three largest payers in Indiana — Elevance Health (68.9%), UnitedHealth Group (17.1%) and Physicians Health Plan of Northern Indiana (5.3%) — represent 91.2% of all privately insured patients with insurance from the large-group market.  

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We are receiving a lot of great feedback on the new "Pediatrics by PRG" module in the Pinson & Tang CDI Pocket Guide, which is the preeminent resource in the CDI space. If you haven't checked it out yet, take a look at the detailed review of over 40 topics that provide guidance to CDI specialists, coders, & clinicians on pediatric and neonatal conditions. This partnership is a key element of how Pediatric Resource Group (PRG) can help hospitals understand the CDI opportunity in the peds/neonatal space and tackle it confidently. If there are other topics you'd like to see, let us know, we can develop and publish those quickly. #CDI #pediatrics #Clinicaldocumentation

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100% satisfaction in birth metrics! What is the secret? Cleveland Clinic achieved 100% satisfaction across five birth metrics, a notable feat that Becker's Hospital Review highlighted. Cleveland Clinic adopted TeamBirth in October 2022. TeamBirth is a care delivery model jointly created in 2021 by Harvard Pilgrim Health Care, Ariadne Labs and UMass Memorial Health. It emphasizes routine check-ins with all patient care team members and family at key points to streamline communication about birth preferences and patient status, using a whiteboard as a key tool. Since adopting it, the health system saw the rate of C-sections for Black mothers go down from 41% to 22%. Rates also improved for white mothers, dropping from 27% to 23%, bringing the outcomes for its patient populations to a more equitable level. ▶ Satisfaction went up across five categories in 2022 to a perfect 100% for: ➡ Friendliness/courtesy of the unit — up 10% from 2022. ➡ Staff concern, information about progress and baby’s condition — up 12% from 2022. ➡ Nurse promptness in responding to patient call — up 12% from 2022. ➡ Nurse's attitude toward patient requests — up 13% from 2022. ➡ Doctor and staff working together during birth — up 15% from 2022. Patient satisfaction grew by 23% — from 72% in 2022 to 95% in 2024 — for how well they felt Cleveland Clinic managed their pain during labour. Transparent communication is important to promoting safety and reliability in high-risk organizations. ♻ How is the communication in your organization? #healthcare #communication #reliability

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Managed Care Negotiation Best Practices - 2025, Class 2. Negotiating Targets and Rebalancing •Know the facts, not the nonsense the insurance cartels and the academics/think tanks report. According to Millman, national commercial reimbursement rates for states range from 136% of Medicare to 266%. You are being underpaid if your rates are below the national average and/or below the average for your state. https://lnkd.in/gJn8xF6y •The average commercial inpatient reimbursement for each state ranges from 152% of Medicare to 261%, with a national average of 202% •The average commercial outpatient reimbursement for each state ranges from 137% of Medicare to 357%, with a national average of 252%. Note: these rates apply to ASCs as well •The average commercial professional reimbursement for each state ranges from 115% of Medicare to 252%, with a national average of 147% - Health systems need to do a better job negotiating professional rates for their affiliated physicians. •Again, the rates you NEED are based on your mix, i.e., Medicare, Medicaid, Commercial, and Self Pay, and the management effectiveness and efficiency of your organization – it is a straightforward calculation •Like hospitals, the insurance cartels must publish their rates. However, they have made it very difficult to analyze their files. If you want assistance with a local rate comparison, contact John and Pete at After Transparency https://lnkd.in/gHDVBEtS •You can’t fight gravity; GI, Orthopedics, Imaging, and several other procedure-based specialties are (and should be) moving to the outpatient setting. Counting on HOPD rates for these outpatient services is a fool’s errand. •Rebalance the commercial fee schedule so that service revenues migrating to the freestanding outpatient setting are priced below traditional HOPD rates but significantly higher than the commoditized rates being offered by the insurance cartels (i.e., At a minimum, target rates of at least 200% of the outpatient Medicare fee schedule) •The revenue reductions in the outpatient rates should be rebalanced to hospital-centric services such as neurosurgery, ED, and NICU. Ultimately, your organization must base its commercial pricing on:  Revenues-Expenses= Survival So it goes n8 Stay tuned for Class 3 - Preparing for the Unwillingness of the Insurance Cartels to Pay Physicians and Hospitals Fairly #hospitals #healthsystems #healthinsurance #healthinsurance

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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A New Tier in Healthcare Services: "TransCare" The traditional framework of healthcare delivery has long been structured around three primary tiers: primary care, secondary care, and tertiary care. These tiers are defined by the complexity of care and the level of specialization required, forming the backbone of healthcare systems worldwide. However, with rapid advancements in technology, we are witnessing a transformation that challenges and extends beyond these conventional boundaries. "TransCare" emerges as a revolutionary new tier in healthcare services, designed to bridge the gaps between these traditional levels and provide a more integrated, accessible, and patient-centered approach to care. Leveraging cutting-edge technologies such as telemedicine, teleconsultation, wearable devices, and robotic surgery, TransCare offers a flexible and seamless healthcare delivery model that caters to the evolving needs of modern patients. Unlike traditional tiers, which often function in silos, TransCare creates a continuous flow of care that follows the patient across different stages of treatment. Whether it's remote monitoring of chronic conditions via wearable technology or conducting complex surgeries with the aid of robotic systems, TransCare ensures that patients receive high-quality care, regardless of their location or the complexity of their medical needs. As healthcare continues to evolve, the introduction of TransCare represents a significant shift towards a more dynamic and adaptable healthcare system. This new tier is not just an addition to the existing framework but a reimagining of how healthcare can be delivered in a way that is more responsive to the demands of the 21st century. TransCare is poised to become a cornerstone of future healthcare, offering a model that is as versatile as it is essential, ensuring that every patient receives the right care at the right time, without the traditional constraints of location or access. As we move forward, the adoption and integration of TransCare into global healthcare systems will likely redefine how we think about and deliver health services, making it an exciting development to watch. SanalBee Pudena Health Consulting Co. Mustafa Köroğlu World Health Organization #TransCare #Telemedicine #HealthInnovation Eric Topol, MD Vivian S. Lee, MD, PhD, MBA John Halamka, M.D., M.S. Ferhan Ö. Alper Utku

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

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Several recently published articles discussing human services portfolio management really resonate. I liked the three Open Minds options for evaluating the viability of each program - keep, fix, close. Rigorous portfolio management is a key to high performing providers and networks demonstrating value. One important topic missing from each of the articles is how to manage the response to and the emotion of program closure. Simple advice for an executive preparing to announce a closure is to brace yourself. Perhaps brace is not a strong enough term - better and more adequate a phrase is 'know your reasons, ensure they relate to your mission and go forward with resolve'. In most cases, the world does not respond positively when providers close programs, and the teams managing the closure underestimate this element of the process. Communities often believe human service providers and hospitals should maintain and expand all services, seldom sympathetic to viability concerns, and even less, portfolio management. It is one thing to manage responses from concerned recipients and a workforce feeling jilted, but teams should also be prepped to address and respond to incensed community members, skeptical state/federal regulators as well as the media's spin on the decision. Realistically, mission-driven agencies focused on strengthening long-term sustainability will be required to close programs at some point, and often the reasons given for closure (regardless how logical) will be challenged by key stakeholders. Preparing yourself and your team, for this element in the closure process and having a solid tailored communication plan in place will ensure it doesn't catch you by surprise and leave you reeling when it happens.

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