MODULE 4: Building Community Networks
In this module, you will learn why community networks are important and about the various purposes a network can serve within a care improvement effort. After reading this module, you will better understand one model of forming and staffing networks as well as some of the challenges that face networks and ways in which these challenges can be addressed.
Why community networks?
While the medical home is central to Community Care’s approach to care improvement, we realize that in many situations even the best-prepared medical home cannot effectively manage and coordinate care alone. This is especially true in cases of chronic illness, as the needs of the chronically ill quickly extend beyond the walls of the medical home. As Ed Wagner has described in his Chronic Care Model, to effectively manage chronic illnesses requires both improvements in how care is organized, delivered and supported within the practice as well as improvements in how care is coordinated, delivered and supported within the community.
To help serve chronic care patients, Community Care developed community networks — local associations of health care professionals and support service providers who share resources and execute care improvement initiatives. These physician-led networks help connect patients and their families with specialists, mental health care providers, hospitals, pharmacists, public health organizations, social service professionals, home health professionals and community-based support service providers. They also help ensure effective coordination and communication across a patient’s full health care team. Networks have been invaluable to our care improvement efforts.
To improve chronic illness care both patient-centered medical homes and patient-centered community care systems are needed. For optimum improvements in chronic illness care, providers who care for patients with chronic illness need to work together in a coordinated way with the patient and the patient’s family. One of the most compelling reasons for organizing the community network is to provide a vehicle for making sure this coordination takes place. This is not the only reason why a well-functioning community network is an important part of the care process.
The role of the community network
Chronic care patients and their primary care physicians (PCPs) often need help navigating the health care system. Depending on the situation, a PCP may call on case managers, pharmacists, behavioral health providers, care managers or chronic care assistants to provide support. To be most effective, this support must be available close to where patients live and receive care.
Large primary care practices that serve many chronically ill patients often embed chronic care support within their practices. Most primary medical care in the U.S., however, is offered through small and mid-size practices for which embedding is neither practical nor affordable. For such communities and practices, there must be a shared care support resource. We have found that a community network can successfully fill this role. The network can also help coordinate and target other community care management resources, such as home health and personal care, through cooperative arrangements with community partners.
By design, a network includes primary care and community providers, making it the ideal vehicle for setting care improvement goals, establishing benchmarks, spreading evidence-based clinical programs and providing performance feedback. The networks, because they bring together essential community providers, are also a natural way to manage other community health issues. Community Care networks, for instance, have addressed a range of problems, from caring for uninsured residents to improving dental and mental health access.
Forming the network
The first step in creating an effective community network is determining the organizations it will comprise. If your program intends to improve the care of a targeted population, then your network(s) must be built around the professionals who serve that population. In the case of Community Care, each of our networks is headed by a steering committee that include, as a minimum, representatives from local medical homes (primary care physicians), community hospitals, county health departments and county departments of social services. At the time our program was launched, North Carolina’s mental health system was in the midst of major reform; had that not been the case, we would have mandated that mental health centers be represented on steering committees as well.
Although these four types of community providers formed the core of each of the14 networks, local networks were encouraged to involve other providers and organizations in their areas. Depending on a network’s mission and needs, it may include an academic medical center, specialists, an Area Health Education Center (AHEC), a mental health center and the county school system. When Community Care expanded its scope to serve aged, blind and disabled Medicaid recipients, even more community providers became involved in the networks, including home health professionals, home- and community-based service providers, hospice workers, nursing homes, assisted-living centers and area agencies on aging.
These cases help illustrate the importance of network flexibility and partnership-building. If, when expanding to serve the aged, blind and disabled, our networks had relied only on their original network partners, results likely would have been poor. There also would have been a group of community providers who care for this population who likely would have felt threatened. Instead, established networks welcomed new colleagues with new ideas and areas of expertise. Making the care improvement process work requires building the partnerships needed to improve the delivery and coordination of care. For example, when the target sub-population was patients with depression, the participating Community Care Networks brought the area mental health center, psychiatrists, psychologists, and community support providers together with the primary care physicians to plan the depression initiative. Each initiative often requires a new set of partners.(Please note, however, that in most cases, new partners are not added to network leadership, which typically includes only community providers who are engaged across a broad spectrum of network activities. For more information on this topic, see “Network organization and staffing” later in this module.)
The role of the state in network formation
While the state, as the primary sponsor, should not play a role in directing or owning networks, it will have a role in supporting and financing network development. It will also be responsible for creating basic ground rules that will guide network formation and operation. These guidelines help ensure a network’s effectiveness. For example, Community Care sponsors did not want to allow providers to establish networks in all of North Carolina’s 100 counties, knowing that such a structure would leave the majority of networks without the leadership or resources to develop and carry out programs. To address these concerns, sponsors required that each network must serve at least 30,000 enrollees, ensuring that small counties would have to ban together with neighboring counties.
With the exception of requiring an enrollee minimum and requiring that networks comprise contiguous counties, program sponsors did not attempt to influence the way networks came together. Instead, these decisions were left to the key providers in each county — the group responsible for forming a network or choosing a network to join.
Just as each network was expected to have a steering committee comprised of, at least, four key Medicaid providers (primary care practices, community hospital, county health department and county department of social services), these same provider organization in each county would also decide which network the county would become part of. This declaration would be made in writing and signed by the county provider organizations.
In general, network formation under Community Care has followed traditional care delivery and service patterns. All but two networks were built around urban medical centers and included neighboring suburban and rural counties. Network formation became difficult or drawn out only in a handful of counties — regions in which provider relationships were divided between competing regional health care systems. Steering committees in all but one county agreed unanimously on the networks they would join; the exception was a county with a hospital operated by an out-of-state management firm that declined to participate in the program. (The program allowed the county to join a network without this hospital partner. This hospital has now become an active partner.) At the end of the network formation process, Community Care had 14 networks (close to our original goal of 15 networks), ranging in size from a two-county, 24,000-enrollee network to one that included 27 counties with 129,000 enrollees.
Network organization and staffing
The organizational structure and staffing of your networks should be driven by the goals of your program. For instance, Community Care was created to improve care and care outcomes for Medicaid enrollees — a mission best accomplished through evidenced-based disease and care management improvement programs created in collaboration with physicians and community providers. To accomplish this goal and develop the needed improvement programs, networks opted for a multi-level structure that could support and sustain the services care improvement would require.
While each network has the freedom to add leadership and staff as it sees fit, all local networks include the following:
- A steering committee that includes primary care physicians and representatives from a hospital, the local health department, the local department of social services and other community health organizations.
- A medical management committee that comprises physicians from the key primary care practices in each network.
- A network administrator who directs local programs and operations.
- A medical director who leads the rollout of evidenced-based clinical initiatives and chairs the network’s medical management committee.
- Care managers, including a mix of RNs and social workers, who comprise the core network staff.
- A pharmacist who directs medication management and e-prescribing efforts.
- A psychiatrist who directs behavioral health integration efforts and provides support to primary care physicians in managing care for patients with behavioral health issues.
- Special project staff members with specialized skills who can support special network initiatives, which in the past have addressed the needs of the uninsured, disparities in care, dental care access and child development.
Leadership, committees and staff are typically organized into a network structure like this:
Because their structure is driven by organizational goals, your networks will evolve as your program grows and changes. When the Community Care program was expanded to include the aged, blind and disabled, networks not only engaged new community providers but also shifted priorities and reengineered core skills. For instance, networks that were formerly focused on improving the care of patients with single diseases like asthma and diabetes developed initiatives to address patients with multiple chronic diseases (as aged, blind and disabled patients often have simultaneous medical and social problems). Major shifts like this can place stress on networks that have been used to one way of business. To improve a network’s ability to take on new responsibilities, the program leadership will have to offer encouragement and comprehensive training that prepares leadership and staff for the new skills that may be required.
In the course of our work with networks in North Carolina, we’ve faced two major challenges: the potential for inconsistent performance among networks, and the risk of poor financial and program management. We believe these are common issues that every network-based care improvement program likely will face. In our experience, each challenge can and should be addressed as soon as it emerges.
The challenge: Ensuring consistent network performance and management. A Community Care network enjoys a great deal of autonomy, which allows it to respond quickly and effectively to local situations and conditions. While Community Care values this independence, the program also wants to ensure that performance — particularly in program-wide initiatives — is consistent from network to network.
- Solution: Community Care has implemented a multifaceted approach to this challenge. To reduce variations in performance, we:
- Hold meetings in which program-wide goals, measures and benchmarks are established and performance is reported.
- Sponsor program-wide trainings at which care managers from every local network receive skill training and are educated on program priorities and expectations.
- Network medical directors, network administrators and network pharmacists participate in monthly conference calls to review programs and network issues.
- Report on network performance. Although program analytics and reporting are conducted at the practice level, key performance measures are reported and shared at the network level as well.
- Create performance agreements that are signed by each network and the North Carolina Department of Health and Human Services. In addition to explicitly stating what the parties will do to achieve success, the Network Memorandum of Agreement contains mutually accepted performance measures for key initiatives that will be analyzed and shared with state leadership. Where performance falls short, networks must develop and implement plans of improvement. Great care must be taken in the design of program measures. We have learned from experience that agreeing to a performance target before we have a thorough understanding of where the improvement opportunities exist and have established accurate baselines for the identified improvement opportunities is a recipe for falling short on targets which should never have been set.
- Solution: To minimize the risk of waste or mismanagement, a program should employ the following safeguards:
- Key members of the management team have the financial skills to oversee budgets and financial operations.
- The board has the skills and processes to provide the necessary oversight of programs and finances through a finance committee.
- An independent program and management audit to guarantee that each network’s program, administrative and financial operations are sound and that necessary oversight exist.
- An annual certified audit is conducted and reported to the finance committee and board.
- Network management has the skills and experiences to effectively manage programs and staff.
- To augment the management and financial skills in new and existing network managers, Community Care is partnering with North Carolina’s Area Health Education Center program to offer network leadership targeted management training.
Points to remember
- Because patient needs often extend beyond the PCP and medical home, the successful care improvement program will employ community care networks — provider-driven local organizations that coordinate care among specialists, mental health care professionals, support service professionals and others.
- Networks can support small and mid-sized practices than cannot afford to employ full-time case managers.
- When organizing a network, begin with a steering committee that will provide leadership and direction. At a minimum, include representatives from primary care practices, a community hospital, the local health department, the local department of social services and the local mental health care provider or agency.
- Allow local networks some autonomy in development, but set appropriate guidelines to ensure that each network can fulfill the mission of your program.
- Every network-based system will face challenges. The key is identifying and addressing challenges early in your process.