MODULE 5: Designing the Program Office

In this module, we will discuss the importance of a central program office, suggesting three possible models. We will review the benefits and drawbacks of each structure. We will also discuss some additional responsibilities and partnerships taken on by the Community Care program office.

Why a central program office?

When building a dispersed medical home and community-based care management system, your program will need to adopt shared performance goals and measures, create policies and provide training and reporting. To do all of these things — and to achieve consistent program performance — you will need a central program office to guide and facilitate the process.

A central program office can sit within the state infrastructure or be independent of the state and be controlled by local networks. You can also create a hybrid structure that is locally controlled but that also maintains strong state ties. Community Care has had experience with all three. (Of course, it would be possible to set up a central program office independent from both the state and local networks, but we advise against such a structure because we believe such an arrangement would undermine the core program principles of local ownership and partnership.)

The state-based program office

When Community Care began operations, all central program activities were managed by agencies of the state. Technical assistance, training, data analytics, reporting and communications were based in the Office of Rural Health and Community Care (a part of the North Carolina Department of Health and Human Services), while the Division of Medical Assistance (the agency that oversees North Carolina’s Medicaid program) handled financing and policy. The success of this shared central support arrangement depended on effective, frequent communication between the two agencies. Under our structure, one person — a shared senior employee of both agencies — was responsible for all key program activities within the organizations. This senior manager who was part of both agencies senior management staff, was able not only to coordinate interagency work but could also identify potential problems (for example, new Medicaid programs or policies that could negatively impact Community Care) and address them proactively.

One of the great challenges of working within a state infrastructure is assembling the team of clinical, technical and administrative staff, and contractors needed to create and maintain a statewide medical home and network system. Even when funding is available, it often takes a great deal of time to establish and fill new positions within the state infrastructure. For cases in which funding has yet to be secured, the hiring or contracting process can seem nearly insurmountable. To work around these challenges, Community Care used a variety of approaches to secure the staff and contractors it needed, including:

• Re-assigning existing state staff to Community Care positions.
• Establishing new positions — particularly administrative positions — that were well established within the state hiring structure. This enabled the personnel part of the process to go much quicker.
• Soliciting in-kind support from partnership agencies and organizations. These groups would often make their staff available to assist Community Care as needed.
• Contracting with organizations that could provide the skills and expertise we needed. For example, Community Care frequently contracted with academic health centers to secure the clinical expertise it needed.
• Securing private funds from foundations and corporate sponsors (primarily pharmaceutical companies) to augment the work that could be done within the state structure. The availability of private funding was an absolute necessity early in our development as we worked to quickly test and spread effective interventions throughout the network.

Another challenge of a state-based central support infrastructure is ensuring that the structure doesn’t undermine the core principles of the program: local ownership and partnership. To prevent that from happening, Community Care participants (including state leadership) agreed to the following operating policies and procedures:

• All clinical and care management programs and elements would be defined and approved by physician and network leadership from participating networks.
• Participants would approve all performance goals and measures.
• To facilitate decision-making and communications, Community Care would ensure that,

The independent program office

Community Care used a state-based program office for more than a decade and found the arrangement beneficial for both the networks and the state. In 2006, however, Community Care (with encouragement from the state’s Department of Health and Human Services) elected to participate in a Medicare Health Care Quality Demonstration known as the 646 Demonstration. This program accepted applications only from provider organizations or organizations representing providers; state agencies could not apply. To ensure eligibility, the 14 networks of Community Care established a central non-profit organization, North Carolina Community Care Networks, Inc. (NCCCN), to apply on their behalf.

To govern itself, NCCCN created a board of directors, giving each network two seats, one of which was to be held by the network’s medical director. Networks with more than 100,000 members received one additional seat for each additional 50,000-member cohort. NCCCN also designated seats for key partners: community hospitals, health departments and departments of social services. The focus of the new central organization would be to put together the application to CMS. If the application was approved then the central organization would, in concert with participating networks and practices, be responsible for implementation.

Although the 646 Demonstration was the primary catalyst for the establishment of an independent central organization, other forces also influenced our decision. First, our long-term vision was to create a program that would improve the quality of care not only for Medicaid recipients but also for all other patients. We knew that to be ultimately successful the change in the care processes and supports would have to be used and measured for all patients of a practice not just the Medicaid patients. The more providers, payers and insurers could agree on a common set of quality improvement goals, standards and processes, lasting improvements in care and care outcomes would be much more likely. Therefore, opening the Community Care medical homes, networks, and care improvement processes to other patient populations became an important long-term strategy. To become the delivery system for all patient populations, Community Care would need an independent central structure. To accomplish this, Community Care has engaged in discussions and proposals with other insurers and payers.

Second, we were influenced by the realities of federal Medicaid fund matching. Under federal guidelines, care management and coordination furnished by state staff and contractors can only draw down federal match at the 50-percent “administrative-match rate.” When non-state providers perform these services, approved expenses can be matched at the “service-match rate,” which is generally higher. Thus, for fiscal reasons the Department opted to provide as many care management and coordination services as possible outside of the state government structure to maximize funding. Thus, in late 2008 many of the technical assistance, data analytics, training and communication services that had been provided within the state were moved to NCCCN.

While implementing an independent structure streamlined our decision-making process and gave us greater control over operational matters such as hiring and contracting, this independence also brought additional risks. Where once Community Care had been embedded within the state infrastructure, a part of the N.C. Department of Health and Human Services, its emerging independence brought new pressures. With the emergence of the independent structure came a shift in the Community Care/State partnership. Increasingly, Community Care was being viewed as an outside contractor rather than the state’s principle strategy for managing Medicaid. Struggling to operate effectively while also maintaining the strong state partnership that had created and sustained the program, we chose to modify our model again. This time, we opted for a hybrid central structure.

The hybrid program office

Working closely with DHHS leadership, Community Care began to define how the state and NCCCN would work together under a hybrid model. The organizations agreed to jointly set program priorities, define accountability, secure needed resources and represent the program within the administration and legislature and with external groups.

In terms of operations, DHHS (through the Division of Medical Assistance and the Office of Rural Health and Community Care) became responsible for financing, Medicaid policy, contracts, compliance and reporting to state officials. Community Care (through its central office, NCCCN) became responsible for training, information services, technical assistance, pilot program management and communications.

To maintain good communication and increase our ability to respond to emerging state needs (including a deepening budget crisis), weekly meetings with the Secretary, DHHS and the Medicaid Director were scheduled. Frequent meetings also occurred with the Governor’s staff, state budget, legislative leaders and staff. Because Community Care’s strong presence within DHHS had diminished, these meetings became an important channel of communication.

Partnerships and opportunities

While its primary mission is to support medical homes and networks, the Community Care central office is also exploring and launching secondary partnerships and projects. While cautious about expanding the scope of our work, we are willing to explore new partnerships if we believe they won’t overtax our resources and will support our greater goal: improving the delivery of health care for all North Carolinians.

Our partnership opportunities are built around the strengths of Community Care:

• Medical Home Model: With more than 1,350 primary care medical homes covering all parts of North Carolina, Community Care has a primary care infrastructure that is available to North Carolina insurers and payers in managing the care of their beneficiaries.
• Local Care Management: While many health insurers and businesses provide or contract with firms for telephonic disease management and health coaching, these services have little contact with a patient’s physician and can’t offer a local presence. With their strong ties to physicians and local care support, Community Care network’s care management, pharmacy management, behavioral health management, and other support can add value to telephonic and other care management efforts.
• Information and analytics:Physicians and other providers have an ongoing need for meaningful information that can help them improve patient care and outcomes. Unfortunately, the availability of data is limited. Through its Informatics Center, however, Community Care is working to integrate pharmacy, lab and hospital data, as well as care alerts and care management information, with risk-adjusted claims data and predictive modeling. Our center will make data and analytics immediately available through provider portals, where it can be accessed by physicians and staff, care managers, and other community providers who care for patients. While the biggest demand for this data rests with physicians, there are many other providers in the care process who also want access to more meaningful data, such as, community hospitals, public health departments and mental health agencies, including professionals working in a range of DHHS-supported programs. We believe that, once fully operational, the informatics center will be useful to insurers, payers and providers alike.

In exploring other opportunities for a central program office, it is important to remain focused on long-term goals. At Community Care, our primary objective is to create a system of patient-centered medical homes and a community-based care support network that improve the quality of all patient care. We recognize that even the most worthy new business opportunity will negatively impact our progress if that opportunity doesn’t directly help us achieve our vision for our program. Only when a new opportunity supports our mission can that initiative be successful.

Points to remember

• All community- and network-based care management programs need a central program office to coordinate activities, measure progress and help providers reach their goals.
• Central program offices can be based within the state infrastructure or can be controlled by the program’s networks and operate independent of the state. You can also create a hybrid model in which the state and networks share responsibilities within the program office.
• Each model has its benefits and drawbacks. The key to success is good communication among all parties involved.
• Your central program office exists primarily to support providers and networks, but may have other opportunities for partnership. While these opportunities may be worthy endeavors, carefully consider how your program office will use its resources. Every activity you undertake must support your ultimate goal: improving care management and outcomes.