MODULE 3: Rolling It Out
In this module, you will learn about the importance of a successful program rollout. We will also discuss some practical steps you can take to help ensure a smooth, effective launch.
A solid foundation
The foundation of any health care delivery improvement program consists of four parts: a thoughtful business plan, a reliable group of supporters, a dedicated management and program staff, and financing. Once you have developed your plan, recruited both supporters and staff, and secured your financing, you are ready to officially launch your program.
A successful launch is immeasurably important to the overall viability of your program. While a badly orchestrated or poorly received rollout does not doom a project to certain failure, it does make future, long-term success more difficult to achieve.
As its primary vehicle for program rollout, Community Care relied on the pilot approach. While the term “pilot” connotes the testing of an idea or set of ideas, it can also be an implementation strategy, where complex program and behavioral change initiatives are piloted (and refined) before program-wide implementation takes place. Community Care has relied on both definitions of a pilot in implementing its programs.
While piloting has served Community Care very well, there has, at times, been pressure to skip the pilot phase and to move directly to program-wide implementation. The pressure has usually arisen because of the need to generate quick savings. Some policy-makers take a dim view of pilots, seeing them more as an exercise in “dabbling” rather than an essential part of program development and implementation. Although understandable, as most pilots rarely move beyond the pilot phase, this view is unfortunate because even great ideas need a testing and refinement phase. The landscape is covered with programs that were rushed to implementation that wound up either as failures or subject to repeated and costly “adjustments”. While a piloting and refinement phase may lengthen the rollout, it can be the difference between success and failure. To avoid the negatives that can be attached to piloting, Community Care has also used “spread strategy” to describe its testing and refinement phase. Under the “spread strategy”, the rollout of an intervention will start in specific communities or networks and will spread under a timeline across all communities and networks. This strategy allows for refinements, adjustments, or even major overhauls of the intervention before it is taken to scale.
Through our experience with Community Care, we discovered — by trial and error, in some cases — six keys to an effective program rollout. By preparing, ensuring participation, providing support, maintaining a “low profile,” choosing its first improvement project with care and offering feedback and praise, Community Care was able to launch a major initiative that was well received by patients, health care providers and policymakers.
Key 1: Prepare
Once you’ve completed the activities described in the first two modules, Getting Started and Developing the Plan and Securing Buy-In, it is time to focus on the launch of your program. Begin with a start-up checklist of every action to be taken prior to rollout. Use that list to draft a detailed start-up plan and timeline, which will describe in detail and by function what structures must be put into place, who will be responsible for each item and by what date each activity must be complete.
Key 2: Ensure participation
Provider participation is critical to the success of your launch. While you will need buy-in from health care professionals at all levels, enlisting the early support of respected community medical leaders will provide valuable momentum as you get your program off the ground.
When we launched Community Care, a primary-care case management program had been in place in the state for more than five years. Known as Carolina Access, this program included primary care practices in all 100 North Carolina counties, which made it easier for us to identify and engage the practices and physician leaders who would be needed for the successful expansion to Community Care.
For states that do not have a Primary Care Case Management (PCCM) program like Carolina Access to build on – do you need to build the PCCM program first or can you put the whole program in place at once? While there is no reason why the development timeline for the complete program can’t be shortened, there are compelling reasons that the development steps that North Carolina followed are the right order. As the underpinning for the entire program, the medical homes must be in place and patients linked to them before the wraparound support to be provided by the networks will have the committed physicians and their enrolled recipients to support.
For our rollout, we contacted all Carolina Access practices with at least 2,000 Medicaid enrollees – 37 practices in all, many of which were pediatric practices. Via a letter from the Secretary of the North Carolina Department of Health and Human Services, we invited providers to partner with DHHS in creating what would be known as Community Care. There were two partnership opportunities.
First, these large Carolina Access practices could sponsor a community network, which would have to include Carolina Access practices, the county’s health department, a community hospital and the county’s department of social services. (The community mental health program would also have been a required partner had North Carolina’s mental health system and the role of the community mental health providers not been undergoing a major reform at the time. As the community mental health system grew more stable, community mental health programs have partnered with Community Care networks in increasing numbers.) Of course, community networks were free to add other community organizations as they saw fit. Sponsors were given the option of forming a limited or comprehensive community network; the former included only Carolina Access practices with large Medicaid enrollments, such as 2,000 members or greater, while the latter included Carolina Access practices of all sizes.
Second, the large Carolina Access practices were also given the option of banning together to form a horizontal network of primary care practices. Under the horizontal model, practices were not required to include other community health organizations in the network.
The response from the initial letter was much stronger than anticipated. Long suspect of “middle man” arrangements, physicians were attracted by the opportunity to work directly with the Department of Health and Human Services in improving the quality of care delivered to Medicaid patients. The fact that they would also be in charge of the quality improvement process was also important. All but one practice opted to participate, with 75 percent of participants choosing to create a horizontal network of large (2,000 to 12,000 Medicaid enrollees) mostly pediatric practices, that were attracted by the opportunity to work together and with 25 percent creating limited or comprehensive community networks.
Because each network was asked to submit a proposal for its planned organization, we held several organizational meetings with the initial practices to review program elements, describe the proposal development process and answer questions.
[Note: Later in the development of Community Care, the community network model became the preferred model. While the horizontal network was very successful, when Community Care was directed by the state legislature to extend its community-based care management system to aged, blind and disabled recipients, it became clear that improving care management for these complex patients would require even greater local collaboration to be successful. The original horizontal model became a hybrid model, comprised of practices and community networks.]
Key 3: Offer technical and financial support
Because our program is a partnership involving both state organizations and local providers, we rolled it out using a time-tested community development process created by community health pioneer Jim Bernstein and the North Carolina Office of Rural Health. Using this approach, the state and the Community Care program office supported the network development process with start-up financing and the technical resources local providers needed to create network proposals, plans and organizations.
To jumpstart the launch process and encourage consistency among the networks, the program office provided each network with a comprehensive assistance package, which included:
- Funding: Each network was eligible for a one-time $30,000 grant — money that could be used to create network organizations and develop start-up plans. Funds could also be used to obtain legal and financial counsel. (A brief application for the funding was required which focused on the commitment and readiness of the partners.)
- A start-up guide: Program staff developed a start-up guide that suggested a step-by-step process for creating a network.
- Access to technical and clinical consultants: Each start-up network was assigned a technical consultant who helped network leadership develop infrastructure and programs. Clinical consultants were also available to provide ongoing training for new clinical and care management staff.
- Creation of the Clinical Directors’ Group: To foster consistency among networks and to establish a process for developing clinical and care improvement programs, Community Care established the Clinical Directors’ Group. Made up of medical directors from participating networks, this group served (and continues to serve) as the official body for establishing program goals, core elements, measures and measurement processes for all clinical and care-improvement programs.
- Work groups: At the direction of the Clinical Directors’ Group, Community Care established work groups that included clinical, management and care-management staff. These groups met on a regular basis to research and design technical guidelines for new care improvement interventions that would be implemented by the networks. Work groups reported their recommendations to the Clinical Directors’ Group for formal adoption.
While networks reported that the support package was extremely helpful, we’ve since realized we should have also offered business operations support. Since most networks were creating new non-profit entities, they would have benefited from advice and instruction in managing funds, personnel, boards and programs. More preparation time should have been devoted to teaching management skills and ensuring that financial oversight processes were in place. Securing technical support from business consultants or engaging business school faculty would have been very helpful during the start-up. Community Care has now partnered with North Carolina Area Health Education Centers program to offer management and leadership training for network leadership.
Key 4: Maintain a low profile
While you could certainly roll out your program with a great deal of fanfare — and there may be situations in which this would be advantageous — we opted to launch the Community Care pilot as quietly as possible.
We had several reasons for this decision. Perhaps the most important was that this was a complex, collaborative initiative. We anticipated the need for trial and error: Some processes wouldn’t work, and those that did work in some networks would need time to spread to the others. In short, we knew it would take time to work out the kinks. Keeping a low profile allowed us to experiment and adjust without excessive distractions.
In addition, we recognized that it could be months or in some cases years before we could clearly demonstrate improvements in care processes and outcomes. If we were successful, we knew there would be data and results that we could share in the future. Rather than spending crucial time on promotion in our early days, we focused our efforts on building infrastructure and processes.
Twelve years after our initial rollout, we still believe our ability to “fly under the radar” during our launch was essential to success. In fact, most participants fondly recall the initial start-up period when our only concern was making the initial vision a reality. While we appreciate the attention we now receive, we’ve learned that increased visibility brings heightened expectations; today, for instance, because our program is seen as a community-based model for improving care, our networks are regularly called upon to address severe state budget issues and tackle new health-care challenges, such as the low-income, uninsured, disparities and obesity. Our new struggle is responding to these growing challenges without short changing the core programs.
Key 5: Select the first initiative carefully
The program launch is not the time to take on a problem so complex that it will likely never be solved or so difficult no other group has addressed it with any success. To maintain participant enthusiasm and generate further excitement about your program, carefully select the first issue you will address — identify an intervention that, if properly executed, can be an unqualified success and serve as a model for future care improvement intervention programs.
In the case of Community Care, clinical leaders selected the improvement of asthma care as the kickoff improvement initiative. We considered the following in making our decision.
- The makeup of practices and networks: In our case, most Community Care participants at launch were pediatricians and family physicians. It was important to begin with an improvement initiative that would capture their attention. Asthma, as a predominately childhood disease, would fit the bill.
- The intricacies of the potential initiative: We chose to pursue an asthma initiative in part because we knew that reaching consensus on the core elements and measures for the program would be relatively uncomplicated. The evidence base for improving the treatment of patients with asthma was well established, and Community Care clinical leaders quickly reached agreement on the core elements and measures of the asthma care improvement plan.
- The potential for success: With some straightforward interventions (asthma patients had an asthma action plan, the severity of their asthma was staged, the most severe were on anti-inflammatory drugs, and where patients were not managing their disease effectively received care management support) the ability of patients to manage their asthma would be significantly improved and dramatic drops in emergency room visits and inpatient hospitalizations would likely occur.
The success of the asthma initiative more than confirmed the selection of asthma care as the kick-off care and disease management initiative.
Key 6: Provide feedback and recognize success
In a health-care delivery improvement program, success depends on changed behavior, and changed behavior comes only as the result of constructive feedback. Evaluating and reviewing progress with participants — and recognizing their achievements and contributions — fosters that change. During the start-up phase, providing reliable feedback is absolutely essential. While Module 7 addresses feedback and accountability in great detail, the importance of a successful start-up warrants a brief discussion here, as well.
First, know that when faced with unfavorable performance data as compared to their peers, some physicians may justifiably argue that their patients are “sicker” — and because they have more health problems than other practices’ populations, they argue the data are skewed. For this reason, it is critical that the data presented have been adjusted for severity to preclude this argument. If physicians do not have confidence in the data, their focus may quickly shift from working toward improvement to feeling unfairly singled out by so-called “biased data.”
In the beginning, it is also important to provide timely, frequent feedback. As the program matures, you may be able to provide feedback at a slower pace, but in the early, formative days, frequent feedback is necessary to help keep new participants’ attention on the project and their performance.
There are several types of feedback that will be useful to practices. Peer data, particularly on quality of care, drives change very effectively, as it is helpful for a practice staff to see how they compare to similar practices. This can also be an effective motivator, particularly if your program is not able to offer financial incentives for exceptional performance. The value of peer data can be quickly undermined if the accuracy of the data is questioned.
Positive feedback and reinforcement will also help drive favorable change. While the start-up period may not be the time to publicize your work, it is the time to internally recognize a participant’s success. In the case of Community Care, the real motivation to work on the program was not the small supplemental funding practices received but rather the opportunity to improve the quality and efficiency of the care they provided. Seeing results and being acknowledged for those results encouraged physicians and their practices in their work.
Points to remember
- After you’ve established a comprehensive business plan, widespread support and a dedicated staff, you are prepared to roll out your program.
- You will likely find a limited rollout beneficial. This pilot will give you time to modify your processes and program before launching it on a larger scale.
- Prepare for rollout with a start-up checklist, plan and timeline.
- Enlist a wide range of practices to participate in your new program. Give each practice ownership of the new initiative.
- Provide participating practices with necessary support: grant funding, clinical and technical training, how-to materials and work groups.
- If possible, keep a low profile. A quiet rollout gives you the time you need to make adjustments and work out kinks.
- Select your first initiative carefully. Address a problem that is challenging but not impossible to correct, and choose an issue that affects and interests participating providers.
- Provide regular and frequent feedback and praise, when appropriate. To be successful, your program needs to spur and foster long-term behavioral change among practitioners and patients. Such change is more likely to occur if program officials not only provide the support tools practices will need in their work but also recognize exceptional efforts and offer suggestions for improvement.