MODULE 1: Getting Started

In this module, you’ll learn more about the principles important to any health care delivery improvement effort: partnership, long-term commitment, support and ownership. You’ll also learn more about setting goals, developing a schematic of your plan, performing a scan of the current health care landscape, and winning the backing of key health care leaders.

The beginnings of Community Care

Although Community Care of North Carolina evolved over 25 years, the program as it currently exists could be replicated in a fraction of that time. When we began, our focus was simply linking patients to physicians. Our initial goals — improving patient access and reducing patient dependency on the emergency room — were modest. They did not address the quality or cost-effectiveness of care, which are two major concerns of our present program.

Thus, were we to develop a similar infrastructure today, we would not start where we did in 1983. We would, however, heed a handful of lessons learned during our initial development process. 

First, the effort was built on principles that have been validated in each subsequent development phase:

Second, the initial development effort incorporated a key development principle: When implementing major reform, pilot and evaluate the program before making a large-scale launch. With a pilot, kinks can be worked out off-stage, where glitches and design flaws won’t cause major harm. For fledgling initiatives, this is invaluable.

Setting goals and adopting principles

Creating an infrastructure that changes the organization and delivery of care requires not only a general plan but also a set of principles that guide all phases of development. In our experience, we’ve found the following principles to be key:

• Partnership. Building a successful community-based infrastructure requires a number of partnerships.

• State/local: A state must be willing to partner with community physicians and other local health care organizations.
• Public/private: Public and private organizations need to work together — both statewide and, more importantly, within the community — to build the community-based systems and secure the statewide support a project like this will require.
• Local/local: Community health providers in many communities work in virtual isolation, often not even knowing, except in a general sense, what other providers do. To collaboratively manage care within a community, the health organizations that provide and support patient care must work together in organizing, delivering and coordinating care for chronic care patients.

• Long-term commitment. Changing how care is provided and delivered requires investment. In a nation that too often demands immediate results, this isn’t an easy sell, but the reality is there are no quick fixes. The medical home and community-based care management approach is built on reengineering how care is organized, coordinated, delivered and tracked within the community for patients with chronic illnesses. This reengineering encompasses system and behavioral change, and to achieve improvement in care and care outcomes, changes must take place in the community. While this approach does not deliver instant results, it builds an infrastructure that can, if nurtured and supported, deliver progressively better results.

• Support. Just as the reengineering effort requires a long-term commitment, it also requires resources and support. There are a number of evidence-based programs readily available to physicians and other providers that, if followed, would dramatically improve the quality and cost-effectiveness of care for patients with chronic illnesses. For the most part, they aren’t used, however, because physicians lack the processes, support or information needed to effectively implement them. An improvement strategy built around medical homes must include a commitment to developing the care support, process improvement and care information required for success. The financial resources necessary for such an undertaking are significant, but without these investments, the prospect for lasting improvement is dim.

• Ownership. One of the notable features of a medical home and community-based care management strategy is that the primary sponsor (in our case, the state) must relinquish substantial control to key participants. In this model, the old adage “he who has the gold makes the rule” does not apply; rather, success requires that those who deliver the care are fully committed to — and have ownership of — the improvements needed. Primary care physicians regularly report feeling overwhelmed, underappreciated and underpaid, and they strongly resist additional responsibilities placed on them without their consent and involvement. Physicians must see that proposed changes will improve their ability to practice medicine and that they are in control of the changes.

Much of the information contained in future modules centers on building and reinforcing the ownership principle because we have found that ownership of the improvement process should be vested in those who must improve. The goals of sponsors or other participants will only have consequence if those charged with meeting the goals are fully committed. Improving guidelines and offering incentives have, at best, short-term impacts. A climate of improvement will take hold and grow only where physicians want to improve, have ownership of the processes and enjoy support and incentives that are aligned to help achieve program goals. Sponsors must be prepared to support — not direct — a physician-led initiative.

Developing a schematic

At this point in the planning process, you will need a broad outline or schematic of what is being considered. The schematic should provide a general overview of the proposed program, including:

This should be a very succinct document (one or two pages) that provides a conceptual framework but few details. The objective of this activity is simply to develop a brief paper that can be distributed to potential stakeholders to gauge interest in the approach and build consensus on the direction.

Conducting an environmental scan

Armed with a schematic, the next step is conducting an environmental scan: a report of the current system and how it works. It should address the following:

• Care systems (managed care, FFS, PPO, other)

• Medicaid patients
• Medicare patients
• Private patients
• Urban/rural patients

• Physician organizations (how physicians practice across the state)

• Large physician group practices
• Small and mid-size physician group practices
• Solo practices or partnerships
• Hospital and physician systems
• Academic

• State Medicaid payments (how providers are paid by Medicaid)

• Prepaid
• Fee-for-service
• Cost-based
• Other

• Leadership (the key health leaders in the state)

• Professional associations
• Academic
• Administrative
• Legislative
• Other healthcare organizations

• Medicaid cost and utilization trends
• Medicaid policy
• Other issues that may impact development

If carried out correctly, the scan will paint a picture of the approaches already in place and point the way to an improvement strategy likely to work. The scan should also indicate the unknowns to be addressed and the hurdles to be overcome. If, for example, the scan confirms that managed care penetration is very heavy in urban communities but almost non-existent in rural communities, then approaching the implementation of a medical home strategy becomes much clearer. An urban strategy will include working with managed care organizations while a rural strategy will require engaging community providers.

A key activity during the scan is identifying the physicians and other leaders from whom you’ll need to secure buy-in to successfully develop and implement a broad improvement strategy. The information gleaned from the scan should also be incorporated into the schematic.

Winning support among key health leaders

With an updated schematic in hand and a clearer understanding of the challenges and opportunities ahead, it is time to begin gauging potential support. Start with medical leaders who will be absolutely essential to a successful medical home effort (consider leaders in the state medical society, family medicine, pediatric medicine, internal medicine, academic medicine, the local medical society, etc.). Put your list together and schedule face-to-face meetings with each influencer to better understand his or her issues and priorities and to begin building rapport. Consider bringing along a respected physician who supports your approach to help shore up your position. These meetings are critical — the physicians who will become the heart of any medical home effort will have to be enthusiastic supporters and become the primary emissaries of the development effort. Beyond physician leaders, you will also need to meet with hospital, public health, academic, specialty, social services and mental health leaders to gauge their openness to the concept and gather their insights regarding potential challenges and solutions. Both types of meetings will help you identify potential supporters.

Use the feedback you receive from these interviews to update the schematic (if needed). If the information learned through the scan and the interviews has been positive and you do not uncover information or receive feedback that would automatically derail or redefine the effort, you are prepared to move on to the next phase: developing the plan and securing buy-in.

Points to remember

• Health care delivery improvement programs require partnerships among providers, local health care organizations and the state.
• Creating community-based care management is a long-term commitment.
• Physicians cannot effectively manage chronic illness care without the necessary processes, support, information and resources.
• Physicians and other providers must be given ownership of the improvement process.
• When planning a medical home approach to care, begin with a schematic (a general overview of the proposed program) and an environmental scan (a report of the current system).
• Use the schematic and environmental scan to win support among health leaders.