Value Propositions: Describing What Is in It for “Them”
With an understanding of the environmental/organizational context and the needs, attitudes, and values of key stakeholders, an investigator/team needs to create compelling messages or “value propositions” for these respective groups. A value proposition is a brief statement of the worth, potential benefits/costs, significance, or importance of an intervention. The concept derives from management consulting where it was formally defined as “a clear, simple statement of the benefits, both tangible and intangible, that [a] company will provide, along with the approximate price it will charge each customer segment for those benefits” (Golub et al., 2000). In the context of disseminating behavioral interventions, this statement or rationale should include both incremental benefits of the intervention for various stakeholders over usual practice (e.g., better outcomes, savings) and an acknowledgment of the costs involved (e.g., staff training costs) (Barnes, Blake, & Pinder, 2009). It is helpful to examine benefits and costs of an intervention for potential end users as early as possible.
A value proposition statement may vary according to the targeted stakeholder. For example, an intervention that provides respite and more time to self might be perceived as valuable to a family caregiver; whereas the low cost for delivery of a particular intervention and brief time for training interventionists may be what is valued most by an agency director who is considering integrating the intervention into its service offerings. Thus, a value statement targeting the caregivers would need to emphasize the respite benefits, whereas the value statement targeting agency directors would need to emphasize the low cost and minimal training requirements. The Hospital at Home program, noted earlier (and described in Chapter 20), improved a variety of health outcomes and lowered the cost of care per patient. However, for fee- for-service-driven hospitals with open beds, which depended on filling those beds and providing services for revenues, this benefit was initially viewed as a negative and a potential “cost” of the intervention (Dr. Bruce Leff, personal communication, January 25, 2015). With the change from fee-for-service to value-based health care, the Hospital at Home program is now more attractive to hospital systems.
An effective value proposition must describe the benefits of an intervention and acknowledge the potential costs. Potential intervention costs include financial (e.g., new salaries, materials, licensing, and/or training fees), marketing, staff time and effort for program implementation, and the psychological costs associated with having to give up (or deimplement) previously held ideas, favorite programs, services, or practices, even if they were not effective, in order to implement a new intervention (Barnes et al., 2009). An effective value proposition must persuasively frame the benefits of adopting the intervention such that the benefits outweigh perceived and real costs.
Take the example of Skills2CareR, a home-based occupational therapy intervention (originally called the Environmental Skills Program) developed and tested by Dr. Gitlin and her team at Thomas Jefferson University as part of the NIH REACH I (Resources for Enhancing Alzheimer’s Caregiver Health) initiative. This program, delivered by occupational therapists, provides education and skill building including environmental modifications, and communication and task simplification strategies to help family caregivers provide better care for persons with dementia. In trying to persuade home health agencies to implement the intervention and train their occupational therapists, Skills2CareR staff first identified a fee structure similar to that of other professional development activities and within the average training budgets of agencies identified through interviews and Web-based research. This cost was then compared to the increased revenue that trained occupational therapists could generate by delivering Skills2CareR for an agency. By integrating the program within the traditional home care treatment of persons with dementia, the family training is reimbursable under Medicare Parts A and B. Despite the initial outlay for training their therapists, adopting agencies could effectively recoup their training costs by taking on 80 new Skills2CareR clients in a year (Gitlin, Jacobs, & Vause-Earland, 2010; Jefferson Elder Care, 2009). As a result, home care agencies could clearly perceive both the value of the program for their clients and understand the investment needed on their part and were thus willing to have their staff trained in this approach. As the training costs fit within an agency’s typical allocation to support continuing education activities of therapists, the program was perceived as a win for therapists, a win for clients and their families, and a win for the agency.
However, a value proposition is not just about its cost savings or financial benefits. Other potential gains may be equally important. For example, demonstrating clinician satisfaction with an intervention either through a formal study or testimonials gathered at the testing phase may be important for convincing doctors, nurses, occupational therapists, social workers, or other health and human service professionals about the value of an intervention. Connecting an intervention to the larger strategic goals of an institution, care system, agency, or community organization can be an important part of the value proposition for administrators and leaders. Similarly, providing national or local recognition for an institution (e.g., positive publicity with a key patient segment or magnet or other meaningful designations) can be a critical part of the value proposition for a hospital, clinical facility, or system leadership.
In developing a value proposition, it is important to consider the following questions:
- ? What would it take to convince a particular stakeholder (e.g., agency director) to support the intervention or invest funds to have staff trained?
- ? What will convince a busy clinician to devote limited time and energy to become trained in an intervention?
- ? What will convince a participant or patient to sign up for, or even pay to receive, an intervention?
- ? What strategies can be used to help offset any perceived costs or barriers?
When creating value propositions, the investigative team may discover that the intervention does not yield enough compelling value for stakeholders. By understanding the values of stakeholders early on in the pipeline, investigators can shape or reshape the intervention accordingly or proceed as planned but with the knowledge of the potential dissemination challenges that will lie ahead. For example, although Skills2CareR created a strong financial value proposition for agencies, some potential adopters could not accommodate the 3 or more days of in-person training that the approach originally required. Agencies perceived it as too disruptive and expensive. The in-person training component was subsequently shortened to 1 day and was complemented by self-directed online lectures and ongoing technical assistance to provide interventionists varied approaches to obtain the needed knowledge and skills to implement the program (Gitlin et al., 2010).
As decisions to adopt a particular intervention are always local, value propositions may not be fully generalizable and will need to be adapted to meet local considerations of different systems, organizations, and communities, all of which have diverse values, cultures, and perceived needs.