MODULE 2: Developing the Plan and Securing Buy-In

In this module, you’ll learn more about developing a blueprint (or schematic) for your program. You’ll also learn more about the broad-base support you’ll need to build for your efforts. As part of this module, you’ll begin to consider the elements of your program — and the importance of consensus regarding this blueprint.

Putting a team in place

Before any plans are drawn for an improvement program, it is essential to establish a team of leaders who will become owners of the plan. This group should include many of the professionals with whom you met during the “getting started” phase. At a minimum, it must include key representatives from the groups that will be expected to lead and carry out the program: family physicians, pediatricians, internists and other physicians, hospitals, public health departments, mental health agencies, community and rural health centers, other community health organizations and academic medical centers. Your leadership group should also include representatives from large health systems or group practices.

In forming this group, bring to the table the professionals who care for patients (particularly Medicaid patients) as these are the providers who will be responsible for heading up medical homes. Choose well-known, well-respected participants who will represent their colleagues’ interests accurately and with integrity.

The initial meeting

Once the leadership group has been formed, convene a kick-off meeting. Your purposes in meeting are to:

Earn the group’s endorsement of the concept.
Discuss, revise and earn the group’s approval of the schematic.
Establish members’ willingness to commit their organizations to the program (as these organizations will be called on to plan, secure support for, develop and launch the initiative).
Receive a group commitment to reconvene periodically to review development and implementation plans.

In addition to earning a broad commitment from the group, identify a smaller group that will work with the state and develop the plan that will be brought before the larger group for endorsement. Like the larger group, this core advisory committee must comprise representatives of your key constituents.

In convening this meeting, consider how it will be facilitated. If the state initiates the event, the meeting should be led by someone at the secretary or director level to command necessary attention. Alternately, the state could recruit a respected, passionate medical professional to lead the meeting. (In North Carolina, we were fortunate to be led by the secretary of the North Carolina Department of Health and Human Services, who was also a highly regarded pediatrician.) We also recommend that the state enlist a few major co-sponsors — medical, hospital, family medicine or pediatric associations, for example. This approach will serve dual purposes: creating awareness and communicating that important groups are behind the program.

If all goes well, you will leave the meeting with authorization to proceed, agreement on a goal and schematic, a planning committee to help to guide the project through the next stage, and a roster of leaders and organizations that stand ready to help make the program a reality.

Developing the blueprint

Now is the time to begin putting details to the endorsed goals and schematic. If your project is a comprehensive medical home and community-based care management system, your blueprint should include development details on many of the following core program areas.

Subsequent modules will provide extensive details on the core development steps. In developing the blueprint, you are simply beginning to provide some of the information and answers necessary to program the implementation. We recommend you consider the following:

Defining the medical home

Who can become a medical home?
What are a medical home’s responsibilities? What are the participation requirements?
How will recipients/beneficiaries be enrolled in or linked to medical homes?
How will a medical home’s performance be measured?
How will medical homes be compensated?
What information/support will be provided to medical homes?
What agreements need to be developed?
What system changes are needed to accommodate the medical home?
How will practices be recruited?

Defining the network

How will networks be formed? Consider:

Size (geographic/number of enrollees/other)
Participants (required organizations/providers to qualify)
Endorsement (government entity/other)
Organizational structure (independent, non-profit, non-profit tied to existing organization, other)

What are the networks’ responsibilities and requirements?
How will recipients/beneficiaries be enrolled in or linked to the networks?
How will a network’s performance be measured?
What services are networks expected to put in place?
How will networks be compensated?
What information/training/support will networks need?
What agreements need to be put in place?
What system changes are needed to accommodate the networks?
What network infrastructure is needed?

Designing and developing care improvement strategies

How will you identify the improvement target areas?
How will improvement opportunities be identified?
Who must participate in the development and approval of improvement strategies?
How will improvement strategies be tested?
What resources and support will be needed?

Developing care management support

For what types of activities will care managers be responsible?
How many care managers will be needed?
How will care managers be integrated into the project?
What training and tools will be needed to support care managers?
How will target populations be identified?
How will performance be measured?
How will care managers be compensated?
What systems will need to be developed to support care managers?
How will care managers be integrated with and support medical homes?

Supporting the medical home in managing chronic care

What other support that is needed (pharmacist, behavioral health, other).
What practice processes and systems need to be improved?
What tools and types of technical assistance are needed to support the improvement process?
How will technical assistance be provided?
How will medical homes access support?
How will support be funded?
What systems are needed to support the improvement process?

Project rollout

How will the project be rolled out? Will there be a pilot program? Will the launch be phased or statewide?
What will the launch schedule be?
What pieces need to be in place before rollout can begin? What pieces are critical?
How will rollout priorities be determined?

Supporting the effort

What is the budget? Start-up? First-year? Five-year?
How will the funds be secured?
What technical support is needed? Community development? Clinical? Data?
What training support is needed?
What materials and tools are needed?
What system changes are needed to accommodate support?
How will the program be represented?
How will you handle communications for participants? Government? Interested parties?
What policy changes are needed?

Feedback and accountability

What information will participants need?
How will this information be obtained?
What program measures will be used and how will they be defined?
What information is needed to drive improvement?
What data/information is needed?
How will feedback be provided? To medical homes? Networks? Others?
How will improvement be measured? Will benchmarks be set? By whom?
How will accountability be communicated?

In December 2009, the Robert Wood Johnson Foundation’s Synthesis Project published “Care Management of Patients with Complex Health Care Needs,” a report that addresses many of the issues you’ll need to consider for your blueprint. We believe this report will be beneficial to any care management start-up project, and we encourage you to review both our summary of the findings and the full report.

As with any part of the program, key decisions about the blueprint must have the support of those who will be expected to carry out the program. Asking the core advisory committee to review, revise and endorse the blueprint is as important as creating the blueprint itself. It is essential that this committee be given time to discuss the document, and the final document must reflect the group’s input and opinions. If the committee process works as designed, the advisory committee will endorse the blueprint and present it to the full committee.

The chair of the core advisory committee should present his or her group’s recommendations to the full group. Because many members of the full committee will not be familiar with the details in the blueprint, it is important to allow sufficient time for questions and discussion. The primary goal of the large meeting is to earn genuine advisory board commitment to the plan. A formal endorsement backed only by a half-hearted commitment will result in discord, roadblocks and inefficiency later in the process.

Gathering further support

With a blueprint in place and a core group lined up to support its implementation, you will face the difficult task of gathering the further support needed to make the program a reality. First, identify the individuals, agencies and organizations that will need to approve and fund the effort. In the case of Community Care, we needed the support of the following:

Director, Division of Medical Assistance (North Carolina’s Medicaid management agency)
Secretary, North Carolina Department of Health and Human Services
Governor’s Policy Staff
Appropriation Subcommittee on Health and Human Services, North Carolina General Assembly
CMS (Medicaid Services) - Revised 1915(b) Freedom of Choice Waiver

This group of administrative and legislative health leaders was critical because it controlled the funds that were needed: state Medicaid funds and federal matching funds. While our concept and program were important to both groups, the prospect of improved performance and savings was what closed the deal. (In the case of CMS, it was the demonstration of budget neutrality that ultimately earned its approval.)

Because state support is so critical (requests for matching federal funds from CMS must originate with the state and be made by the designated state agency), it is essential that key administrators, legislators and agencies begin to hear about the proposed program as development begins. While they don’t need to approve a specific plan and budget yet, you’ll want their endorsement of the concept early in the process. It may be unrealistic to expect each key leader to jump on board, but if either the state Medicaid agency or department of health and human services is going to be the program’s primary sponsor, their leadership must be fully committed. Thus, while you are lining up support from key provider organizations, you must also shore up support within key government agencies. Use your provider leaders to help earn this backing.

Once support from key providers, administrators and legislators is in place, turn your attention to those individuals and organizations unlikely to endorse the program but that are not critical to its operation or success. While earning their approval would be ideal, your immediate goal is simply ensuring they won’t work to derail the project. The best way to accomplish this is to provide them with information about the initiative and an opportunity to discuss it. At best, they will get excited about the project and offer support; at the least, they will not be able to say they weren’t told about your plans. Most likely, those you meet with will appreciate being informed and be relieved that they won’t be impacted. (If they will be impacted, however, extra care must be taken in this outreach.)

To make the most out of these meetings, first put a list together of the individuals and organizations to be briefed and then, using your bank of supporters, decide on the best people to conduct the briefing(s). We caution against inviting potential detractors to a general information session as such sessions are fraught with risk — they are unpredictable and individual concerns can quickly grow into major issues. If you do call for a general meeting, be sure you have enough support in place (and present) to neutralize any opposition.

While every landscape is unique and every group will need to earn support from different stakeholders, we sought (and won) endorsements for Community Care from the following groups:

North Carolina Medical Society
North Carolina Hospital Association
North Carolina Pediatric Society
North Carolina Academy of Family Physicians
North Carolina Association of County Commissioners
State Health Directors’ Association
Academic Medical Centers
Area Health Education Centers

Consider similar groups in your area when planning your approach.

Once you’ve secured the backing you need, addressed possible detractors and created a schematic, you and your core committee are ready for the next step of program development: enabling program sponsors to gather needed resources. Armed with a blueprint and a strong base of support, sponsors can begin firming up the political and financial support needed to implement the program.

Points to remember

To help ensure the success of your improvement program, establish an advisory board of physicians, hospital, public health, and academic medical center leaders who will become owners of the plan.
From this advisory board, form a smaller workgroup that will drive development of the initiative.
Once the advisory board has approved program goals and the schematic, draft a more comprehensive program blueprint. The blueprint should define the medical home, suggest a process for developing improvement strategies and explain how support will be provided.
Asking your core advisory committee to review, revise and endorse the blueprint is as important as creating the blueprint itself.
Use the blueprint to win further support for your concept. Review the plan with the individuals, agencies and organizations that will need to approve and fund the effort.