MODULE 6: Supporting the Effort
Since a majority of states already have a primary care case management (PCCM) program in place to serve at least a part of their Medicaid population, the focus of this module will not be in describing the many support components that go into putting a PCCM or medical home infrastructure in place. Rather, this module will concentrate on describing the essential steps in creating and maintaining a community-based care management infrastructure.
Supporting Community Networks for Success
Supporting the formation of community care networks is a multi-part process. First, networks will require start-up funding and technical support to develop the organization, do their planning, secure staff and design care improvement initiatives. This is Phase I. Once networks are established, they will need an ongoing source of funding as well as data and technical support to deliver and implement their care and quality improvement initiatives that, in most cases, will be best developed in collaboration with other participating networks. This is Phase II.
- To provide funding for infrastructure development, planning, initial staffing and day-to-day operations, we suggest program sponsors award each network a one-time start-up grant to offset initial expenses. Community Care provided each of its 14 networks with approximately $30,000 in start up funds when the program first began. Most of this funding was used to secure part-time technical staff who, in conjunction with the local board of directors, created basic network infrastructures and programs.
- In the early days, many of your networks will need experts who understand community development principles (i.e., consultants who can facilitate the development of a grassroots, community-owned and -operated network). Take time to find professionals who understand not only community organizing but the local health care delivery system, as well. Your community development consultants do not need to be either on-staff or full-time. They do need to be able to go into a community and facilitate and support the development of an effective community-owned and operated network.
Great skill is required to help ensure that the new network puts in place the leadership, staff, plans and processes that will be needed for success while reinforcing community ownership and decision-making. Successful community organization will result in an effective and independent community network that is not dependent on the organizer. During our start-up phase, Community Care employed four half-time community developers: two contract consultants and two staff members who handled additional program responsibilities. The consultants assisted the networks in building partnerships, establishing its organization, hiring staff and developing an operational plan. Each consultant supported two or three networks with their development processes. The level of consultant support needed depended on the size of the network, the complexity of development issues and the availability of local developmental resources.
- Medical community outreach
- The success of a medical home-centered, community-based care management system depends in large part on whether local physicians adopt and enthusiastically commit to the program. To ensure provider participation across a broad geographical area, your program will need a team of medical leaders who will be ambassadors for the program. As practicing physicians employed by your program as consultants, these providers must be highly respected by their peers and able to promote the initiative with conviction and skill. Typically, these medical leaders already have been prominent within their community and within state medical associations.
- As part of your outreach team, these consultants should be enlisted to attend various medical society meetings (county, state and specialty) and hospital/physician staff meetings on behalf of your program. Physician consultants can also be extremely effective in representing the program to hospital and other community health organizations. (Because of time and cost limitations, it is usually impractical to ask physician consultants to visit individual practices unless the practices are exceptionally large or of particular strategic importance.)
In the case of the Community Care start-up, the central program office employed three part-time senior medical leaders who worked with network medical leaders to help build local medical support and engagement for the program. They were joined in their work by a number of volunteer physicians who, because of their commitment to the program’s goals, offered to speak on behalf of the project in their communities. These volunteer medical leaders were absolutely essential to effectively reaching and engaging community physicians during the early stages of program development.
- Quality and Process Improvement
- To help networks design quality and care improvement programs, we recommend securing three types of consultants: (1) clinical experts who will focus on specific disease management initiatives; (2) specialists who will concentrate on quality improvement program development; and (3) process improvement specialists who will help practices upgrade care management processes for their chronic care patients.
- To support the development of specific disease management initiatives, Community Care identified and engaged clinicians from academic medical centers who had the necessary expertise. These short-term engagements provided participating networks and physicians with the resources they needed to develop program elements, measures and performance goals. These experts also provided training and technical assistance as needed.
- Quality improvement consultants
- To support networks in the development and implementation of quality and care improvement programs, Community Care engaged physicians and registered nurses who had expertise in implementing quality improvement programs targeted at both children and adults. When Community Care began to focus on patients with multiple chronic illnesses, quality improvement consultants shifted their attention from single disease efforts to broad-based chronic care efforts. In all cases, quality improvement staff supported networks in developing and implementing their programs and in training staffs and practices.
- Practice improvement consultants
- To help practices strengthen their skills in managing the care of patients with chronic illness, Community Care partnered with North Carolina’s Area Health Education Center program (AHEC) to provide technical support. AHEC established a team of practice improvement consultants who worked closely with network quality improvement staff to help network practices improve their care processes and to adopt new care improvement tools.
- Once networks have been created, they will require ongoing funding to operate. The scope (and to some degree, the success) of your program will depend on the financing you secure; and to secure financing, you must convince those who have or control funds that your program is a worthy investment not just in terms of improved patient outcomes but also improved cost efficiency.
- Community Care began by requesting funding from the N.C. Division of Medical Assistance (the state’s Medicaid agency), the N.C. Department of Health and Human Services, the Governor’s office, the N.C. General Assembly and CMS. Winning support required far more than simply justifying the financial request; many other forces had to be aligned to make it happen. When we approached funders, we were prepared with a business plan (including measurable objectives and timelines) designed to give funders confidence they would see a return on their investment. It’s important to remember that public and foundation funders want to see that their investments in a new health initiative will return improvements in care and reduce or control health care spending.
- To earn funder confidence, you must present a complete and realistic plan for your initiative. Also, for a new, untested program, you’ll need to consider a staged approach to financing. With an initiative like Community Care where there was neither a track record nor good examples to cite, a staged approach to securing the needed financing was adopted. For example, when we presented the concept for Community Care, potential funders supported the idea but wanted to see real–world results before making a major investment. Knowing this, Community Care requested minimal financing — a budget just large enough to pilot and test the concept. Through the pilot program, Community Care had the opportunity to test and refine our approach and build a body of experience and specific measurable outcomes before seeking statewide funding.
- Under the pilot, the program initially received a go-ahead and funding to launch nine community networks in eight counties and establish one horizontal primary care network across a number of counties.
- Ongoing funding
Once the successful pilot was completed and the administration and legislators directed the program to expand statewide, Community Care developed a business plan and budget for creating and sustaining a statewide medical home and care management system. The major elements of Community Care’s implementation budget were:
- Medical Homes
- All states with a Medicaid Primary Care Case Management (like Community Care) program pay a per-member per-month (PMPM) payment to participating primary care practices, and rates may vary based on the patient populations that are included. In North Carolina, primary care practices receive $2.50 PMPM for TANF-related groups (Temporary Assistance for Needy Families, primarily children and women) and $5 PMPM for the more complex aged, blind and disabled enrollees. These payments do not necessarily cover a practice’s cost of participating in care improvement activities, but these enhanced care management payments have, along with better than average Medicaid physician reimbursement, and strong state-wide physician leadership created a very high level of primary care physician participation in Community Care.
- In addition to physician participation, recipient participation will also determine the budget needed for the medical home portion of the project. We believe mandatory enrollment, when allowable, should be part of the medical home program. If this is the case, participation levels will likely reach 70 to 75 percent based on Community Care’s experience. For cases in which enrollment is voluntary, such as with dually eligible populations, 10 to 20 percent participation is more likely unless other actions are taken. Our enrollment of dual-eligible residents, who enroll voluntarily, has been running at 12 percent. To improve enrollment, the Division of Medical Assistance is pursuing an opt-out process. Under this process, a dually eligible beneficiary is notified that he or she will be automatically enrolled with the primary care physician he or she has been seeing most recently unless the beneficiary indicates otherwise. For this strategy to work, however, the identified practices must be willing to enroll all of these recipients. This strategy has already increased the percent of dual eligibles who have enrolled in Community Care to 29 percent. Only six percent of the dual eligibles who have been reached through the opt-out process have elected not to enroll.
- In addition to PMPM fees to be paid to participating providers, a primary care case management program must also address the costs of enrolling recipients into the program, educating them about the program and their choices, and making necessary changes to the state’s management information system.
- Enrollment and education can be handled by an independent broker or through county departments of social services (North Carolina chose the latter). North Carolina’s social services departments assumed responsibility for enrolling recipients in the program, helping them select a medical home and reviewing education materials with them. In the early days of the program, the Division of Medical Assistance also provided each department with funds to hire a managed care representative to educate and support department staff in carrying out Community Care enrollment and education functions. These dedicated representatives proved to be critical to the successful launch of the program. In fact, they were so valued that a number of social services departments sought and secured funding to retain these experts when state funding for their work was cut during a difficult budget year.
- A fledgling primary care case management program will also face significant expenses associated with changes to the Medicaid Management Information System (MMIS) as it must be updated to accommodate the enrollment of recipients, the linking of recipients to primary care practices, and accommodating any referral authorizations. Although these system changes are covered under federal MMIS match rates, the state will still have to come up with 10 percent of the needed funding.
- Finally, your organization will require long-term and stable funding for its core network functions, which include case management, medical direction, pharmacy management, behavioral health management, information and privacy, and administration.
- If your program cannot bill for these services, you will need to identify another funding mechanism. In the case of Community Care, the network activities were funded using the same mechanism that funded medical home activities: PMPM payments. These payments, called “enhanced care management payments,” are made to the networks by the Division of Medical Assistance’s fiscal intermediary in North Carolina. Established through a State Plan Amendment, these payments are eligible for federal matching funds at the service rate. (They should also qualify for the enhanced federal match available to states under “Health Homes for Enrollees with Chronic Conditions” provision of the Patient Protection and Affordable Care Act.) Once the PMPM rate is set, networks receive regular payments based on the number of network enrollees.
- While this mechanism for funding operations is very attractive, it does come with a couple of limitations. First, these are service payments for loosely defined care management activities. To help ensure that payments are used for the purposes intended, it is imperative that the state has a memorandum of agreement with each network specifying expectations and how enhanced care management payments can be used. Second, once the PMPM rate is set, it can only be changed with great difficulty. Planners, therefore, have to accurately calculate the resources networks will require for enhanced care management activities. This is a daunting task and requires that planners identify all care management services that will be provided and predict which Medicaid populations will be enrolled and what their needs will be.
- Community Care set its initial network payment at $3 PMPM to cover care management services for a predominantly AFDC population. When the North Carolina General Assembly asked Community Care to extend its medical home and care management support services to aged, blind and disabled (ABD) recipients, the General Assembly provided additional funding, which was converted into a new PMPM for the more complex aged, blind and disabled recipients ($8 PMPM).
- Although the enhanced payment for ABD enrollees has helped the networks provide additional care management resources, the needs of these complex patients — many of whom have three or more chronic conditions — have outpaced the resources available. At the time of this writing, we were working with the N.C. Department of Health and Human Services to secure additional funding to better address the needs of high-risk enrollees who require additional support.
- Informatics and analytics
- While your central program office can support your networks in a number of valuable ways, perhaps its most important function is generating the information and analytics providers and networks need to manage enrollee care, drive quality improvement and measure progress in reaching performance goals. While obtaining timely and meaningful data is never easy, it is nearly impossible for local providers and networks to do so on their own.
- When Community Care began, Medicaid claims data was the primary source of performance statistics. While not always timely, it provided rich utilization and cost information to guide implementation efforts. As the program matured, program participants recognized that physicians and network staff would need more robust data to manage day-to-day care. The central office began developing an information center that would be responsible for capturing and reporting real-time pharmacy, lab, hospital, care management data and care alerts that are integrated with Medicaid utilization and cost data. (Medicare data will be added as well in the near future.)
- Approximately 70 percent of Community Care’s central staff is devoted to building the Community Care Informatics Center and offering analytical support to providers, networks, public agencies and central quality improvement staff. This has required a large but absolutely essential investment.
- Clinical and quality improvement
- Because the program is built on networks that operate independent of one another, we’ve found that strong, central support for clinical and quality improvement is essential to creating consistency within the program. Community Care’s central clinical and quality improvement staff includes a mix of physicians and health care professionals who have both specific clinical expertise and the leadership and communication skills necessary for helping networks and providers design and implement quality improvement initiatives. The ongoing work of clinical and quality improvement staff includes building consistency in program operations, designing and testing new interventions, rolling out program-wide initiatives, training and educating participants and using information and analytics to provide feedback that will drive improvement.
- The structure of your administrative staff will depend, in part, on how your program is organized. If your central program office exists as part of the state structure, then securing necessary administrative staff will likely require creativity and patience. Even in states where strong support for your initiative exists, increasing the size of the bureaucracy is rarely if ever popular, and you may meet resistance to your staffing requests.
- To secure the clinical and technical staff needed, Community Care relied on a combination of state and private foundation funding and on private resources, primarily from pharmaceutical companies. The foundation and private resources were absolutely essential to secure quick, timely staffing. Community Care partnered with a private non-profit organization, the North Carolina Foundation for Advanced Health Programs, to secure the funding and hire and/or contract for the key clinical and technical staff. The program primarily relied on the state to secure those staff resources that fit more easily within a state structure, such as general program administration and support staffing. This combined staff was housed in and directed by a state agency, the North Carolina Office of Rural Health and Community Care.
- This combined approach worked well in the early days of the program. As the scope and complexity of the program grew, however, and the program considered the possibility of serving new populations (including Medicare beneficiaries), a new approach was needed. With encouragement from the state, the Community Care Networks created a new structure: North Carolina Community Care Networks, Inc. This organization became the new home for most of the central clinical and technical staff. Program administration was split between the state and NCCCN; auditing, reporting and financing are handled by the Department of Health and Human Services while NCCCN’s central office oversees program administration, accountability and communications. The Department of Health and Human Services and NCCCN work together on strategic planning and goal setting.
- In addition to the administrative functions, NCCCN has two activities — legal and communication services — that warrant special mention.
- Legal counsel is essential for any health care improvement organization as it will undoubtedly face complex issues. For Community Care, one of our largest legal engagements involved health information exchange. As mentioned earlier, our central organization provides practices and networks with health data, including personal health information on enrollees. To ensure the ethical exchange of this data, our legal team has worked with DHHS to develop a provider agreement that would protect the exchange of personal health information. As the area of health data exchange is complicated and ever-changing, our reliance on legal counsel was costly but absolutely crucial. For its legal services, Community Care contracts with a large North Carolina firm that has significant expertise in health-related issues. A senior partner from the firm is on retainer to provide general counsel; specific attorneys with particular expertise are engaged, as needed.
- Communications counsel and assistance is provided through resources from NCCCN. Good communications are critical to the success of a medical home- and community-based care management system that depends on improved care processes and behavior. Our communications effort comprises:
- Quarterly program-wide meetings for senior medical and administrative leaders.
- Quarterly meetings to address targeted initiatives, such as chronic care.
- Training sessions and printed manuals for all new care managers.
- Program website.
- Program newsletter.
- Start-up guides.
- Program reports on key interventions.
- More than two-thirds of Community Care’s central operation budget is dedicated to the development and operation of the Informatics Center. The remainder of the budget is divided among clinical and other program support and administration. About 20 percent of the continuation budget (along with the majority of any carry-over funds) is apportioned to design and test new initiatives within the networks. These pilot initiatives have become Community Care’s primary method of conducting research and development.
- The majority of funding for the central organization’s budget comes in the form of monthly payments from the networks. Each network sends the central organization $2 per member per month for every ABD enrollee. These payments come out of their enhanced care management payments they receive from the Division of Medical Assistance.
Points to remember
- Your networks work independently but will require strong central support, both during launch and for ongoing operations.
- At launch, your networks will need three types of support: community development experts, medical community ambassadors and clinical/technical staff (who will help create initiatives, improve processes, etc.).
- After launch, your networks will continue to require clinical and technical support. They will also need general administrative support, including communications and legal counsel.
- Your networks and practices will need performance data and analysis to improve their care management. Collecting, studying and distributing this information is perhaps the most important service your central program office can provide.
- We suggest offering networks three levels of funding: a start-up grant for initial costs, pilot funding for your initial test run and ongoing funding for day-to-day operations. Community Care funds the majority of its work through Medicaid per-member, per-month “enhanced care management” payments.
- When requesting funding from the state or your sponsors, consider a phased approach: a small amount of funding for a pilot program and a larger amount when your pilot can demonstrate results and success.
- A realistic and comprehensive business plan will be required to secure funding from state and foundation sources.
- Recruiting qualified physicians and other consultants is a critical step in generating the necessary support for your program at the local level.