Shaping more efficient and accessible clinical services

Nancy Shanley’s career reflects a deep commitment to enhancing Medicaid services for older adults, people with disabilities, and people with chronic illnesses. With more than 20 years of experience in clinical psychology and healthcare policy, she brings a unique blend of expertise and empathy to her role as vice president of consulting and policy analysis to our clinical services team at Maximus. 

Nancy collaborates with state governments to refine the delivery and application of long-term services and supports (LTSS) assessments. Her efforts help ensure timely access to care while tailoring programs to provide the right care in the right setting at the appropriate intensity for an individual’s unique needs.

My post-academic career started in psychology, and I worked for 15 years as a therapist. I served around half of my caseload pro bono — helping adults, children, and families in need. The people I had the privilege of serving were primarily from low-resource households, and their lives had been significantly impacted by situational conditions, behavioral health concerns, or intellectual and developmental disabilities. 

That experience led me to become a specialist in therapeutic intervention for people with complex needs, much like the Medicaid population seeking long-term services and support that we serve at Maximus. I helped adults with serious mental health conditions and children with intellectual and developmental disabilities and behavioral issues. I encountered many people experiencing the generational impact of trauma or abuse. Everyone I worked with taught me so much about dignity in the midst of difficulty and the supports that can fuel resilience and respect. Being able to make a difference in their lives made a huge difference in my life. 

Then my father became ill. I knew his increasing needs would likely threaten his ability to stay at home. So, I took a sabbatical, moved back home, and helped my mother care for him. He could live the remainder of his life in the home he loved, sitting in a chair so old and comfortable that it was permanently molded around him, with the people he cared about, and keeping up the everyday habits that had become meaningful to him. I think staying at home allowed him to live a little bit longer, but I know it allowed him to live a great deal happier.

Looking back, I realize that much of what I do today for Maximus blends and extends my early work in behavioral health and the tremendous opportunity to help my increasingly frail father remain inside his community, in his home, and around his people at that critical juncture in his journey.

After my dad passed, as a prelude to reentering the “paid” workforce, I explored new ways that work could allow me to plug in and be useful. I took some time to reflect on how I could contribute and went on a “talking tour.” I approached people with a reputation for being very good at what they do and very happy in their lives. I asked them about their jobs and what they liked about them, with the additional request to refer me to three more people who were exemplary at work and happy in their lives. These discussions led me to discover a role that fit me well. 

During my talking tour, I met some folks with some interesting assessment projects that helped states deliver crucial services that changed the lives of people with long-term support needs. I asked them how they spent their days, what they found rewarding, and the skills needed to move one of these projects from "okay" to "excellent."

But they turned the tables and started asking me questions! They asked about my leadership approach. I told them that as a therapist, my job was to lend support so that by the end, I wasn’t the leader of a person's recovery; they were. Next, they asked about my proficiency as a multitasker. I quoted research that suggested multitasking was inefficient and said I was a "confirmed serial monotasker." I answered every question personally and honestly, even if it contrasted with business norms.

We discussed my research at Vanderbilt University and how much I enjoyed the precision of my work. Then they started connecting dots I didn’t see — assessments require precision, and assessment programs require an intense focus on excellence and quality, but also an understanding of people — and offered me a role.  

Happily, I accepted and implemented the company’s first assessment projects in Tennessee and began to grow our business by focusing on how we could best help states make a difference in the lives of the persons they served. When Maximus acquired this company in 2016, I became part of another growing clinical services practice.

I’m particularly proud of our work on the PASRR program. At one point, it struck me that states were completing the tasks required by PASRR regulations but missing an opportunity to change lives or help meet their mental health or intellectual and developmental disabilities goals. The assessments were getting the job done in terms of compliance but weren’t necessarily improving lives, rebalancing systems, or informing initiatives for home and community-based services.

We worked closely with the Centers for Medicare & Medicaid Services (CMS) and state agencies to raise the bar on what PASRR programs could achieve as tools for real change. We saw the conversations between CMS and states start to focus more on accurately identifying persons with disability and transitioning them to supported community settings.

Today, something that was initially viewed as a regulatory task is seen as a viable tool to help tip the balance from institutions to home and community-based services, improving the quality of life for so many people with disabilities.

Across all of our assessment and determination work, we deliver the services our state clients ask of us. But we always ask ourselves, "How can we help yield greater benefits for the state, the individuals we serve, or the providers that depend on our assessments?" These everyday musings often lead to meaningful conversations with our clients about how a tweak, change, or evolution of current practices can create more value within the broader system.

Conflict-free assessments are conducted by organizations with no financial stake in the outcome. This means they don’t have any financial incentives to overestimate or understate the measures of supports needed by individuals. In other words, there’s a risk that when non-objective organizations make determinations, these decisions could be influenced, overtly or unintentionally, by financial interests. As an independent entity, Maximus focuses on each person's individual needs when determining the right supports and setting.

However, independence alone doesn’t make assessments or determinations accurate. Assessment entities must also enforce clinical protocols and have operational infrastructures that support accuracy and statewide consistency in determining outcomes.

Accuracy also requires a person-centered approach, including an awareness and accommodation of the backgrounds and experiences of the people we assess. When considering someone's needs, our assessments may not capture their true support needs if we don’t interact with them within their cultural context.