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.

PHASE I

• Start-up funding

• 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.

• Community development

• 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.

• Clinical experts

• 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

• 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.

PHASE II

• 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.

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.