Case Study Organized Health Care Delivery System • June 2009 Community Care of North Carolina: Building Community Systems of Care Through State and Local Partnerships D ouglas M c C arthy and K imberly M ueller I ssues R esearch , I nc . The mission of The Commonwealth ABSTRACT: Community Care of North Carolina (CCNC) is a public–private partnership Fund is to promote a high performance between the state and 14 nonprofit community care networks. The networks comprise health care system. The Fund carries essential local providers that deliver key components of a “medical home” for low-income out this mandate by supporting adults and children enrolled in Medicaid and the State Children’s Health Insurance independent research on health care issues and making grants to improve Program. Community-based delivery systems promote the development of locally led health care practice and policy. Support approaches that leverage resources and relationships to meet statewide goals. Local net- for this research was provided by works and primary care physicians receive supplemental funding for care management and The Commonwealth Fund. The views quality improvement initiatives supported by statewide performance measurement and presented here are those of the authors benchmarking activities. Results suggest that the program has yielded cost savings while and not necessarily those of The promoting improvements in care of patients with chronic conditions. CCNC’s experience Commonwealth Fund or its directors, officers, or staff. may be relevant to other states considering how to improve primary care case management programs, or how to better address the needs of low-income individuals in areas that lack effective mechanisms for coordinating care. For more information about this study, OVERVIEW please contact: In August 2008, the Commonwealth Fund Commission on a High Performance Douglas McCarthy, M.B.A. Health System released a report, Organizing the U.S. Health Care Delivery Issues Research, Inc. System for High Performance, that examined problems engendered by fragmen- dmccarthy@issuesresearch.com tation in the health care system and offered policy recommendations to stimulate greater organization for high performance.1 In formulating its recommendations, the Commission identified six attributes of an ideal health care delivery system (Exhibit 1). Community Care of North Carolina (CCNC) is one of 15 case study sites To download this publication and that the Commission examined to illustrate these six attributes in diverse organi- learn about others as they become available, visit us online at zational settings. Exhibit 2 summarizes findings for CCNC. Information was www.commonwealthfund.org and gathered from staff in the CCNC central office and from a review of supporting register to receive Fund e-Alerts. documents.2 Although case study sites varied in the manner and degree to which Commonwealth Fund pub. 1219 Vol. 8 they exhibited the six attributes, all offered ideas and lessons that may be helpful 2T he  C ommonwealth F und Exhibit 1. Six Attributes of an Ideal Health Care Delivery System • Information Continuity Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems. • Care Coordination and Transitions Patient care is coordinated among multiple providers, and transitions across care settings are actively managed. • System Accountability There is clear accountability for the total care of patients. (We have grouped this attribute with care coordination, since one supports the other.) • Peer Review and Teamwork for High-Value Care Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care. • Continuous Innovation The system is continuously innovating and learning in order to improve the quality, value, and patient experiences of health care delivery. • Easy Access to Appropriate Care Patients have easy access to appropriate care and information at all hours, there are multiple points of entry to the system, and providers are culturally competent and responsive to patients’ needs. to other organizations seeking to improve their capa- promote local responsibility for systemwide principles bilities for achieving higher levels of performance.3 of collaboration, population health management, and accountability. ORGANIZATIONAL BACKGROUND Each local network is a nonprofit organization Established in 1998, CCNC is a public-private partner- that facilitates a partnership among essential local ship that provides key attributes of a primary care providers including hospitals, primary care physicians, "medical home" and care management for almost one county health and social service departments, and million low-income individuals enrolled in Medicaid other key stakeholders that vary from network to or the federal-state Children's Health Insurance Program network (e.g., county medical societies, which help (CHIP).4 CCNC is a community-based delivery build relationships with specialist physicians). Several system that builds on and enhances the state’s networks also include state-designated local Medicaid primary care case-management program, management entities that oversee and coordinate the known as Carolina ACCESS, which has been in provision of local mental health, developmental operation since 1991. disability, and substance abuse services. CCNC has grown from a pilot project into a More than 1,300 primary care practices with program encompassing the entire state through 14 non- approximately 3,500 to 4,000 physicians currently par- profit community care networks (Exhibit 3) that cover ticipate in CCNC networks statewide, representing geographic areas ranging from a single county to a about half of North Carolina’s primary care practices. region comprising 27 counties (one network includes Physicians contract with the state’s Department of provider sites dispersed among counties throughout the Medical Assistance to participate in Carolina state).5 Networks were developed by local physicians ACCESS, then contract with a local community care and other Medicaid providers through a request-for- network to participate in CCNC. Key participation proposals process initiated by the state. This state– requirements include providing primary preventive local partnership is structured to leverage local care services, assuring 24-hour coverage, coordinating resources and relationships to meet local needs and C ommunity C are of N orth C arolina : B uilding C are S ystems T hrough S tate & L ocal P artnerships 3 the use of specialty care, and participating in care Office of Rural Health and Community Care serves as management and quality improvement activities. a central program office under the sponsorship of the The State of North Carolina partners with the state’s Department of Health and Human Services. The program to provide resources, information, and technical North Carolina Foundation for Advanced Health support, such as analyzing Medicaid claims data and Programs, a nonprofit organization, also provides staff- sponsoring statewide audits for performance measure- ing and grant-funding opportunities. ment and benchmarking purposes. The North Carolina Exhibit 2. Case Study Highlights Overview: Community Care of North Carolina (CCNC) is a public–private partnership that provides key components of a medical home and care management for almost one million low-income individuals enrolled in Medicaid or the State Children’s Health Insurance Program. CCNC is a community-based system of 14 regional networks, each of which is a nonprofit organization consisting of a partner- ship of local providers including hospitals, primary care physicians, county health and social services departments, and other stakeholders. More than 1,300 primary care practices with approximately 3,500 to 4,000 physicians currently participate in CCNC networks statewide, representing about half of the primary care practices in the state. The state provides resources, information, and technical support. Physician fee-for-service reimbursement is supplemented by a per-member per-month (PMPM) fee for case management. The regional networks also receive a PMPM fee to cover the cost of care management and network administration. Attribute Examples from Community Care of North Carolina Information Partners with Blue Cross Blue Shield to promote electronic pre­ cribing statewide with planned educational, techni- s Continuity cal, and grant support. Plans to use savings from other initiatives to promote the adoption of EHR among local essential providers. Care managers in regional net­ orks use a common Web-based case management information system to track w patients and their assessments, facilitate care plan­ ing, and engage in secure mes­ aging. n s Care Coordination Develops and disseminates resources and tools to support population-health management for Medicaid patients. and Transitions; Local networks hire nurse case managers who work in concert with physicians to identify high-risk patients, assist in System patient edu­ ation and follow-up, coordinate care, and help patients to access services. c Accountability* Networks collaborate with other community agencies (such as the local health department and mental health agency) to coordi­ ate care. n Peer Review and Network clinical directors identify best-practice models and create systemwide quality measures and initiatives; Teamwork for local networks implement initiatives locally. High-Value Care Local clinical directors work with peers in the community to support and encourage quality improve­ ent efforts. m Physicians receive comparative performance profiles (compiled by the CCNC central office) to motivate improve- ment on network initiatives. Continuous Innovative delivery model in­ orporates principles of public–private partnership, physician leadership, quality and c Innovation population management, shared responsibil­ty, and incentives. i Chronic disease initiatives have increased adherence to clinical guidelines and improved outcomes such as re- duced asthma-related emergency visits and hospitaliza­ions. t A sustainable community-based infrastructure helps launch other health initiatives. Easy Access to Each CCNC patient selects or is assigned a primary care physi­ ian who serves as a “medical home,” providing c Appropriate Care acute and preventive care and facilitating access to specialty care and after-hours coverage. Networks work with their medical homes to increase after-hours and weekend availability. Mental health integration pilot colocates behavioral health specialists in primary care and, obversely, creates access to preventive primary care services in behavioral health practices. Local networks are partnering with local safety-net providers and indigent-care programs to create integrated networks of care for uninsured adults. * System accountability is grouped with care coordination and transitions, since these attributes are closely related. 4T he  C ommonwealth F und Exhibit 3. Community Care of North Carolina Access II and III Networks Alleghany Ashe Northampton Gates Ca Cu Surry Stokes Rockingham Caswell Person Vance Warren m rri Granville Pa de tu sq n ck Watauga Halifax Hertford uo P Per Wilkes ta C Chow nk qu Yadkin Durham Alamance Orange im ima Avery Forsyth Franklin Mit Guilford Bertie an ns s Nash ch Yancey Caldwell Alex- h Davie ell ander Edgecombe Madison Iredell Wash- Wake Martin ington Tyrrell Burke Davidson Randolph Wilson Chatham Dare McDowell Catawba Rowan Buncombe Pitt Beaufort Haywood Swain Lee Johnston Hyde Lincoln Greene Rutherford Cabarrus Graham Henderson Mont- Harnett Wayne Jackson Stanly gomery Moore Polk Gaston Lenoir Cherokee Cleveland Mecklen- Macon Transyl- burg Craven vania Cumber- Pamlico Clay Richmond Hoke land Sampson Jones Union Anson Duplin Scotland Onslow Legend Robeson Bladen Carteret Pender AccessCare Network Sites New AccessCare Network Counties Columbus Hanover Access II Care of Western North Carolina Brunswick Access III of Lower Cape Fear Carolina Collaborative Community Care Carolina Community Health Partnership Central Carolina Health Network Community Care of Wake / Johnston Counties Community Care Partners of Greater Mecklenburg Community Care Plan of Eastern Carolina Community Health Partners Northern Piedmont Community Care Northwest Community Care Network Partnership for Health Management Sandhills Community Care Network PU5 Acce ss II III 9 -2 0 0 7 Southern Piedmont Community Care Plan The state pays local networks $3.00 per member tions, for example by providing preventive care services per month (PMPM) to cover the cost of network and identifying patients in need of care management. management activities, including the salaries of a full- time program director, a part-time medical director, INFORMATION CONTINUITY full- or part-time consultant pharmacists, and a team Many physician practices participating in CCNC have of care managers. Network management fees are not yet implemented electronic medical records. To intended to be competitive with those charged by encourage adoption, Community Care plans to use commercial disease management vendors for similar savings from other initiatives to promote the adoption services. Some networks also receive grant monies of health information technology among local essential for specific initiatives relevant to their respective providers. In the interim, CCNC is partnering with enrolled populations. Blue Cross Blue Shield of North Carolina on a state- Physicians are paid on a fee-for-service basis wide electronic prescribing initiative. The CCNC cen- (fees are set at 95 percent of Medicare rates), supple- tral office will provide educational, technical, and mented by an additional $2.50 PMPM for medical home grant support to help participating practices adopt the and population-management activities.6 This supple- technology to transmit prescriptions electronically and mental funding helps providers take a more active role thus improve administrative efficiency and patient in managing the health needs of their patient popula- safety. Some local networks are developing related information technology solutions. For example, one C ommunity C are of N orth C arolina : B uilding C are S ystems T hrough S tate & L ocal P artnerships 5 network provides its physicians with handheld com- collect data on process and outcome measures. puters that include tools for promoting cost-effective During home visits, for example, care managers drug prescription.7 assess medication use for review by a consul- Care managers throughout the program use a tant pharmacist and provide feedback to pri- secure, Web-based case management information sys- mary care physicians when patients are not tem (CMIS) to help coordinate the care of enrollees. adhering to their treatment regimen. The system includes modules for patient information • Care managers also assess the psychosocial such as diagnoses and service use derived from claims needs of patients and address barriers to care data; reporting on guideline compliance at the individ- such as communication or transportation needs. ual and population levels; patient assessment and care For example, care managers may assist patients planning to document problems, goals, and interven- in scheduling follow-up appointments and tions provided; and secure messaging among care by facilitating access to community-based ser- managers. The CCNC central office supplements the vices for behavioral health care, housing and CMIS with additional data derived from Medicaid shelter aid, or vocational and family support claims to help identify patients with target conditions when needed.8 and measure service use. Data derived from chart audits are used for measuring process and outcome • A care-transitions program is currently under quality to assess performance. development as part of the chronic care initia- tive to help reduce hospital readmissions among CARE COORDINATION AND TRANSITIONS: patients with complex chronic illness. In the TOWARD GREATER ACCOUNTABILITY FOR Cumberland Network, for example, care manag- TOTAL CARE OF THE PATIENT ers based in the hospital coordinate directly CCNC’s care management activities are designed to with hospital staff to facilitate patient transitions help mitigate the long-term medical and financial risks to the community. from poorly controlled chronic diseases. Local com- Each case manager is responsible for monitor- munity care networks hire case managers who work in ing a population of 3,000 to 4,000 Medicaid patients concert with primary care providers (“medical homes”) (all patients are assigned to a case manager regardless to identify patients who will benefit most from tar- of their current need for service), typically managing geted care management interventions, such as patients an active caseload of 150 to 200 patients. Because care making repeated ER visits; patients diagnosed with managers may coordinate care for patients across mul- asthma, diabetes, or heart failure; and patients who tiple physician practices, they seek to develop personal have two or more chronic conditions (including mental relationships with physicians in the network so that health conditions) with high service use or activity they can effectively communicate about patient needs.9 limitations indicating complex care needs. Care man- To ensure consistency across the system, CCNC net- agers identify high-risk patients through the CMIS and work leaders and program staff collaborated to develop from case-identification lists provided by the CCNC the Standardized Case Management Plan, which offers central office, notifications of admissions provided by benchmarks and guidelines for care management activ- hospitals, and physician referrals. ities and reporting across networks. The plan includes action steps for network coordinators and case manag- • Care managers assist in patient education and ers, as well as strategies for characterizing service follow-up to promote treatment adherence and intensity levels. support lifestyle changes, help patients coordi- CCNC contracts with Area Health Education nate their care and access needed services, and Centers (AHECs) to conduct randomized chart reviews 6T he  C ommonwealth F und of a representative sample of patients seen in each par- Local medical management committees ticipating practice to assess compliance with care man- implement these statewide initiatives, along with their agement guidelines. The clinic receives feedback from own, locally developed initiatives, using a rapid-cycle this audit to help improve the delivery of care. Local quality improvement model. Local clinical directors providers generally view the activities of the case work with peers in the community to support and managers as offering added value to the services pro- encourage quality improvement efforts. Networks vided by the practice. In a recent study of innovations covering multiple counties may also designate part- in rural primary care management, physicians com- time physician “champions” to work with physician mented positively that care managers “add tangible practices in each community. Some networks also benefits for the patient that the provider does not have employ quality improvement “coaches” to assist in time to offer.”10 practice redesign efforts, although this is not yet a systemwide undertaking. PEER REVIEW AND TEAMWORK All CCNC networks work together with the FOR HIGH-VALUE CARE state to define, track, and report performance mea- Clinical directors elected by each regional network sures. Clinical directors choose performance measures meet regularly to select targeted diseases or care pro- that are evidence-based best-practice guidelines and cesses for improvement. The group adheres to certain can be measured using existing data sources, such as guiding principles in selecting a quality improvement Medicaid claims and chart audits. CCNC physicians initiative (Exhibit 4). The group reviews and identifies receive a quarterly practice profile detailing their per- relevant best-practice models, creates networkwide formance on utilization and disease management mea- quality initiatives, defines outcome and process mea- sures, such as total costs per member per month and sures, and rolls them out to local practice sites. rates of asthma hospitalizations and diabetes control. Outcome data may include utilization measures, while process data may include periodic assessments or CONTINUOUS INNOVATION treatment planning. Claims databases and regular chart The public–private partnership and community-based reviews provide a source for collecting and monitoring delivery model promotes the development of targeted these data. Clinical areas targeted for improvement initiatives that can be developed in a flexible manner to statewide include asthma, diabetes, and heart failure, meet local, regional, or statewide needs, and the bene- along with appropriate use of medications (specific fits of these initiatives can be shared among the networks. initiatives will be described in the next section). Exhibit 4. CCNC Guidelines for Selecting a Quality Improvement Initiative • There are sufficient Medicaid enrollees with a particular disease to obtain a return on investment by improv- ing its treatment. • Evidence exists that best practices lead to predictably improved outcomes. • Appropriate evidence-based practice guidelines are readily available. • Physicians support the process. • Patient education and support can lead to improved outcomes. • Best practices and outcomes are measurable, reliable, and relevant. • There is room for improvement: A gap exists between best practice and everyday practice. • There is a quantifiable baseline from which to measure improvement. C ommunity C are of N orth C arolina : B uilding C are S ystems T hrough S tate & L ocal P artnerships 7 Asthma Initiative. The asthma initiative supports phy- trained to work with physicians to educate patients in sicians in: 1) improving routine identification, assess- disease self-management, targeting those at highest ment, and severity staging of asthma to determine risk. CCNC reports increases in the provision of some appropriate treatment; 2) reducing unintended varia- chronic care services, such as blood lipid testing, tions in care through adherence to national practice which was received by 66 percent of diabetics in 2004 guidelines; 3) educating patients, families, and school as compared with 77 percent in 2005. personnel in asthma management; and 4) reporting An analysis of diabetes outcomes found that in outcomes. Program results reported by CCNC appear 2006, on five of six measures, CCNC met or exceeded promising. a benchmark set by the National Committee for Quality Assurance’s Diabetes Physician Recognition • Since the program’s inception in 2004, there has Program (Exhibit 6).11 For example: been a 21 percent increase in severity staging and a 112 percent increase in the administering of flu • Forty-seven percent of CCNC diabetes patients shots to asthma patients. More than 90 percent of achieved optimal control of their blood sugar staged patients are using appropriate medications. (hemoglobin A1c less than 7 percent), versus the benchmark of 40 percent. • Between 2003 and 2006, asthma-related hospital- izations decreased 40 percent, from 2.6 to 1.5 • Fifty-six percent of CCNC diabetes patients admissions per 1,000 member-months, and achieved optimal control of blood cholesterol emergency visits decreased 17 percent, from (LDL-C less than 100 mg/dL), versus the 13.2 to 11.0 visits per 1,000 member-months benchmark’s 36 percent. (Exhibit 5). In a locally developed refinement of this state- Diabetes Initiative. The diabetes initiative promotes wide initiative, Cabarrus County established a disease the use of the American Diabetes Association’s management center and registry to sharpen their focus Clinical Practice Recommendations, along with tools on diabetes. The registry tracks process and outcome to support their implementation. Case managers are measures including hemoglobin A1c, blood pressure, Exhibit 5. Community Care of North Carolina: Inpatient Admissions and Emergency Department Use by Patients with Asthma Inpatient Admissions Emergency Department Use Rate per 1,000 member-months* Rate per 1,000 member-months* 3.0 15.0 13.2 2.6 12.3 11.9 2.2 11.0 2.0 10.0 1.6 1.5 1.0 5.0 0.0 0.0 FY 2003 FY 2004 FY 2005 FY 2006 FY 2003 FY 2004 FY 2005 FY 2006 * Rate includes inpatient admissions or ED visits with a diagnosis of asthma. Source: Community Care of North Carolina, Disease and Care Management Initiatives, 2007. 8T he  C ommonwealth F und Exhibit 6. Community Care of North Carolina: Diabetes Outcomes Compared with Benchmark, 2006 Percent of diabetes patients Community Care NCQA Benchmark 100 80 60 56 47 40 37 36 37 40 34 35 25 21 15 19 20 0 HbA1c BP control LDL control HbA1c BP control LDL control control <130/80 <100 control ≥140/90 ≥130 <7.0%* mmHg* mg/dL* >9.0% mmHg* mg/dL* Good Control: Higher Rates Are Better Poor Control: Lower Rates Are Better Note: Benchmark is National Committee for Quality Assurance, Diabetes Physician Recognition Program, thresholds to achieve recognition in 2006. HbA1c = hemoglobin A1c; BP = blood pressure; LDL = low-density lipoprotein cholesterol. * Indicates that CCNC rate meets the benchmark threshold. Source: Adapted from B. D. Steiner, A. C. Denham, E. Ashkin et al., “Community Care of North Carolina: Improving Care Through Community Health Networks,” Annals of Family Medicine, July/Aug. 2008 6(4):361–67. eye, and foot exams, regardless of patients’ coverage. and reduce costs where appropriate. These efforts led Practices use the data to evaluate and improve the to more than 8,000 recommendations, 74 percent of delivery of care, as well as to compare the care which were implemented, and an estimated $9 million received by Medicaid and uninsured patients with that in cumulative savings since 2002, according to pro- provided to privately insured patients.12 gram figures. CCNC reports that this effort improved patient health care through reduction of drug duplica- Prescription Advantage List. The prescription advan- tions and adverse drug–drug interactions. tage list (PAL) is a voluntary drug list developed by In addition to these statewide initiatives, local CCNC clinical directors and the North Carolina community care networks undertake their own targeted Physicians Advisory Group in cooperation with the initiatives. For example, AccessCare—a statewide net- state. The list ranks drugs within therapeutic categories work with the largest registry of pediatric Medicaid (by highest frequency and opportunity to impact qual- patients in the state—engaged in a quality improve- ity and cost) to encourage the use of less-expensive ment intervention for gastroenteritis that reduced hos- drugs, including generics and over-the-counter medica- pital admissions to levels substantially lower than tions, whenever appropriate. CCNC providers receive those of a control group. Key components of the inter- quarterly feedback on a PAL scorecard showing the vention included expert-led physician education on percentage of prescribed PAL drugs and the use of evidence-based care, peer-to-peer teaching and sharing over-the-counter medications for their enrolled popula- of tools and resources, and performance feedback.14 tion. CCNC reports that this program has been associ- ated with lower overall pharmacy spending and annual EASY ACCESS TO APPROPRIATE CARE savings of nearly $1 million by the state.13 Medical Home. Each CCNC enrollee selects or is assigned a personal primary care provider who serves Nursing Home Polypharmacy Initiative. The initia- as a “medical home.” This role extends to providing tive reviewed drug regimens of 9,000 nursing home acute and preventive services and facilitating patient Medicaid patients and made recommendations to phy- access to care through specialty referrals and after- sicians in order to optimize overall drug management hours coverage. Some networks work with their medi- C ommunity C are of N orth C arolina : B uilding C are S ystems T hrough S tate & L ocal P artnerships 9 cal homes to increase after-hours and weekend avail- holders together to help break down barriers between ability. Providers in Pitt County, for example, created a disciplines and to address policy issues such as dis- community pediatric after-hours clinic staffed by a crepancies in payment and regulations. pediatrician and medical residents offering services during the evening hours every day of the year.15 HealthNet Collaborative Networks. Under the state’s CCNC engages patients in the medical home HealthNet program, CCNC networks are partnering model through an educational campaign called “The with local safety-net providers and indigent care pro- Right Call Every Time: Your Medical Home.” The grams (such as free clinics and reduced-fee programs campaign touts the value of preventive services and offered by community and rural health centers and continuity of care with the same practice. In addition public health departments) to create integrated net- to distributing patient-education materials that inform works of care for uninsured adults.16 The goal is to patients of the benefits of a medical home, providers leverage CCNC’s case management capabilities and and care managers work with patients on shifting physician pool to increase the number of uninsured triage toward the primary care setting and away from with a medical home, improve accessibility and qual- the ER when appropriate. ity of care, and promote continuity of coverage regard- less of the funding source. By creating a single triage Mental Health Integration. In the last two years, four process to assess and meet the needs of low-income CCNC networks have worked with state mental health individuals—who often alternate between periods of agencies and local management entities to pilot a eligibility and ineligibility for Medicaid coverage—an model for integrating mental health care into routine integrated program helps assure that patients receive medical care. This program seeks to better manage appropriate care while also conserving free care and Medicaid enrollees with co-occurring behavioral and other resources to serve more of those in need. physical health needs, and to serve them in the most The state provides technical assistance and appropriate setting by: 1) providing education, funding to support 16 HealthNet collaborative net- resources, and support to primary care physicians to works that serve uninsured adults with incomes up to increase their comfort level in identifying and treating 200 percent of the federal poverty level. Local net- depression in their patients; 2) improving communica- works set eligibility criteria and operating parameters tion and coordination between primary care physicians based on local resources and capabilities. The and behavioral health care specialists; and 3) imple- HealthNet program will reach about 45,000 uninsured menting a system of standardized screening and adults in 27 counties during its first year, with plans to assessment tools and evaluation measures. expand to 10 more counties in the coming year. The The Mental Health Integration pilot has led to CCNC case management information system is being several communitywide mental health planning efforts updated with software functionalities used by indigent and to a grant program to help offset the start-up costs care networks for enrollment and referral, managing involved in colocating mental health professionals in provider commitments, and tracking service utilization primary care sites. Another pilot innovation is “reverse and value of care provided for the uninsured population. colocation,” which creates access to preventive pri- mary care in behavioral health practices. To promote RECOGNITION OF PERFORMANCE this complex change in practice (a much more difficult In addition to the results of the specific interventions undertaking than traditional clinical practice improve- described above, Exhibit 7 discusses areas where ment), CCNC is participating in the statewide ICARE CCNC is achieving higher levels of performance. Partnership (www.icarenc.org), which brings stake- 10T he  C ommonwealth F und Exhibit 7. Externally Reported Results and Recognition Overall An actuarial analysis by Mercer Human Resources Consulting estimated that, compared with Financial historical fee-for-service costs, the program saved the state between $284 million and $314 Performance million in fiscal year 2006. A more conservative estimate of what the State would have spent “without any concerted effort to control costs” suggests savings of $154 million to $170 mil- lion attributable to CCNC’s care management and quality improvement activities in 2006.17 Ambulatory University of North Carolina researchers evaluated the program’s disease management pro- Care Quality grams and estimated a $3.5 million savings resulting from the CCNC asthma management program and a $2.1 million savings resulting from the CCNC diabetes management program during 2000–2002.18 National CCNC received the 2007 Annie E. Casey Innovations Award in Children and Family Systems Recognition Reform from the Ash Institute for Democratic Governance and Innovation at Harvard Univer- sity’s John F. Kennedy School of Government. According to the institute, “Community Care’s centralized structure enables medical directors to develop improvements in care treatments and to influence the generation of larger-scale public health programs that share model prac- tices statewide.”19 INSIGHTS AND LESSONS LEARNED Stakeholders shaped the program around five key CCNC was created to enhance and build upon North principles: 1) a public–private partnership that unites Carolina’s existing primary care case management pro- and strengthens local essential providers; 2) physician gram through community-based organized delivery leadership and local control; 3) a focus on quality of systems that could manage large populations. Primary care and population health management; 4) shared care providers working alone simply did not have the state/local responsibility; and 5) shared incentives. tools, information, or support to manage care for the Steiner and colleagues point out that this federated state’s many Medicaid beneficiaries with complex med- organizational structure enables statewide collabora- ical and social problems. Under the CCNC program, tive learning while also promoting local physician par- these community health partners have come together in ticipation and stronger linkages with the community partnership with the state to employ a population health than would be likely under a more centralized management approach in existing practice arrangements. approach. While local control helps communities This system of care was created through an evo- respond to local needs, it also means that quality lutionary, collaborative process involving state offi- improvement remains variable across the state. cials, physician leaders, and professional organiza- Participation in local community care networks tions. According to University of North Carolina pro- can empower primary care physicians, whose role in fessor of family medicine Beat Steiner, M.D., M.P.H., the health system is often undervalued in traditional and his colleagues, some of the factors contributing to care arrangements. “Doctors can come to the table to the success of this statewide system include visionary meet with other players and offer input [on how to and sustained leadership, a strong state infrastructure improve care],” says Chris Collins, M.S.W., a program to oversee the program, starting small to demonstrate consultant to CCNC and formerly an executive direc- success at a local level, and disseminating best prac- tor of a local network, who notes that this “gives them tices through pilot programs. The perceived external a voice to drive change from the bottom up.” Giving threats of possible federal funding cuts and outside physicians an opportunity for involvement increases interference from commercial insurers also motivated their motivation to engage in network quality improve- physicians to try a new approach.20 ment initiatives, she says. C ommunity C are of N orth C arolina : B uilding C are S ystems T hrough S tate & L ocal P artnerships 11 Current challenges affecting CCNC’s future better address the needs of Medicaid and CHIP development, according to Steiner and colleagues, patients in areas that lack effective mechanisms for include the adequacy of the network management fee coordinating and improving care. Savings gained from to fund effective care management for high-risk popu- an improved coordination of care could be used to lations, the need to extend care coordination to include help fund public program enrollment expansions. not just primary care physicians but subspecialists who How the financial and clinical results achieved in treat patients with complex care needs, the ability to North Carolina would compare with outcomes attained parlay focused quality improvement initiatives into in other state Medicaid programs with alternative larger practice redesign efforts that can lead to trans- forms of managed care (such as those that contract formative system-level change, and the limitations of with private health plans) remains a question for current data systems in supporting robust outcomes further evaluation. measurement. Comparison to other case study sites In summary, local community care networks are suggests that CCNC could realize further improve- a central element in the strategy to provide access to ments through structural interventions such as the quality health care for low-income citizens of North adoption of electronic health records and the “advanced Carolina. A community-based approach to implement- access” model of patient scheduling, which can reduce ing enhanced primary care case management appears patient waiting times and increase practice efficiency. to be promoting broad physician participation and CCNC’s experience may be relevant to other making more effective and efficient use of resources to states considering how to improve the effectiveness of help improve population health. primary care case management programs, or how to For a complete list of case studies in this series, along with an introduction and description of methods, see Organizing for Higher Performance: Case Studies of Organized Health Care Delivery Systems— Series Overview, Findings, and Methods, is available at www.commonwealthfund.org. N otes reports of the State Division of Medical Assistance; 1 T. Shih, K. Davis, S. Schoenbaum, A. Gauthier, and the following publications or presentations: R. Nuzum, and D. McCarthy, Organizing the U.S. S. Wilhide and T. Henderson, Community Care Health Care Delivery System for High Performance of North Carolina: A Provider-Led Strategy for (New York: Commonwealth Fund Commission on a Delivering Cost-Effective Primary Care to Medicaid High Performance Health System, Aug. 2008). Beneficiaries (Washington, D.C.: American Acad- emy of Family Physicians, June 2006); R. Arora, J. 2 Information on CCNC was synthesized from a Boehm, L. Chimento et al., Designing and Imple- telephone interview with Chris Collins, M.S.W., menting Medicaid Disease and Care Management program consultant for Community Care of North Programs: A User’s Guide (Rockville, Md.: Agency Carolina; e-mail communication with L. Allen for Healthcare Research and Quality, Mar. 2008); D. Dobson, M.D., vice president for clinical practice L. Hewson, “Improving Medicaid Quality and Con- development at Carolinas Healthcare System and trolling Costs by Building Community Systems of formerly assistant secretary for health policy and Care,” presented at the Medical Homes Summit of medical assistance in the North Carolina Depart- the National Academy for State Health Policy and ment of Health and Human Services, and with Beat the Patient-Centered Primary Care Collaborative, Steiner, M.D., M.P.H., professor of family medicine Washington, D.C., July 2008; D. L. Hewson, “The at the University of North Carolina at Chapel Hill; North Carolina Experience,” presented at “Com- feedback from staff in the CCNC central office; a munities Connect: Putting the Pieces Together,” a review of supporting documents including those on conference held in Seattle, Wash., June 2008. Other the CCNC Web site (www.communitycarenc.com); sources are noted below. 12T he  C ommonwealth F und 3 A summary of findings from all case studies in the 13 Mercer Government Human Services Consulting, series will be found in D. McCarthy and K. Mueller, Letter to Mr. Jeffrey Sims, State of North Carolina Organizing for Higher Performance: Case Studies Division of Medical Assistance, Aug. 2005. Avail- of Organized Delivery Systems. Series Overview, able at www.communitycarenc.com. Findings, and Methods (New York: The Common- wealth Fund, 2009). 14 A. J. Zolotor, G. D. Randolph, J. K. Johnson et al., “Effectiveness of a Practice-Based, Multimodal 4 As of January 2009, CCNC served a total of Quality Improvement Intervention for Gastroen- 970,544 individuals statewide, including 874,766 teritis Within a Medicaid Managed Care Network,” Medicaid beneficiaries (of which 132,134 were Pediatrics, Sept. 2007 120(3):e644–e650. aged, blind, and disabled individuals) and 95,778 children enrolled in CHIP (known as North Carolina 15 C. F. Willson, “Community Care of North Carolina: Health Choice). This enrollment represented about Saving State Money and Improving Patient Care,” 75 percent of all Medicaid and CHIP beneficiaries North Carolina Medical Journal, May/June 2005 who were eligible to enroll in managed care pro- 66(3):229–33. grams. 16 Information on HealthNet was obtained from Anne 5 The Central Carolina Health Network (shown on the Braswell, senior analyst and HealthNet program map) is a subnetwork of Access Care Network. manager, North Carolina Office of Rural Health and Community Care. 6 Physicians receive $1.50 per member per month for participating in Carolina Access, and an additional 17 K. Lurito, Mercer Government Human Services $1.00 per member per month when they join a local Consulting, Letter to Mr. Jeffrey Sims, State of community care network. North Carolina Division of Medical Assistance, Sept. 2007. Available at www.communitycarenc.com. 7 S. Wegner, presentation at the workshop “Appro- priate Drug Use and Prescription Drug Programs: 18 T. C. Ricketts, S. Greene, P. Silberman et al., Adding Value by Improving Quality,” sponsored by Evaluation of Community Care of North Carolina the Agency for Healthcare Research and Quality, Asthma and Diabetes Management Initiatives: Denver, Colo., Nov. 5­ 7, 2001, http://www.ahrq. – January 2000–December 2002 (Chapel Hill, N.C.: gov/news/ulp/pharm/pharm7.htm. University of North Carolina, Apr. 2004). 8 P. Silberman, S. Poley, and R. Slifkin, Innovative 19 Ash Institute for Democratic Governance and Inno- Primary Care Case Management Programs Operat- vation, Community Care of North Carolina Honored ing in Rural Communities: Case Studies of Three as Innovations in American Government Award States (Chapel Hill, N.C.: Cecil G. Sheps Center Winner (Cambridge, Mass.: John F. Kennedy School for Health Services Research, University of North of Government, Sept. 2007), http://www.innovation- Carolina, Jan. 2003). saward.harvard.edu/AnnieECasey.cfm. 9 B. Steiner, A. C. Denham, E. Ashkin et al., “Com- 20 Steiner, Denham, Lashkin et al., “Community Care munity Care of North Carolina: Improving Care of North Carolina,” 2008. Through Community Health Networks,” Annals of Family Medicine, July/Aug. 2008 6(4):361–67. 10 Silberman, Poley, and Slifkin, Innovative Primary Care, 2003. 11 Steiner, Denham, Lashkin et al., “Community Care of North Carolina,” 2008. 12 L. A. Dobson, Jr., and T. L. Wade, “Cabarrus County: A Study of Collaboration,” North Carolina Medical Journal, May/June 2005, 66(3):234­ 36. – C ommunity C are of N orth C arolina : B uilding C are S ystems T hrough S tate & L ocal P artnerships 13 A bout the A uthors Douglas McCarthy, M.B.A., president of Issues Research, Inc., in Durango, Colo., is senior research adviser to The Commonwealth Fund. He supports The Commonwealth Fund Commission on a High Performance Health System’s scorecard project, conducts case studies on high-performing health care organizations, and is a contributing editor to the bimonthly newsletter Quality Matters. He has more than 20 years of experience working and consulting for government, corporate, academic, and philanthropic organizations in research, policy, and operational roles, and has au­hored or coauthored reports and peer-reviewed articles on a range of t health care–related topics. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. During 1996–1997, he was a public policy fellow at the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota. Kimberly Mueller, M.S., is a research assistant for Issues Research, Inc., in Durango, Colo. She earned an M.S. degree in social administration from the Mandel School of Applied Social Sciences at Case Western Reserve University and an M.S. degree in public health from the University of Utah. A licensed clinical social worker, she has more than 10 years’ experience in end-of-life and tertiary health care settings. She was most recently a project coordinator for the Association for Utah Community Health, where she supported the implementation of chronic care and quality improvement models in community-based primary care clinics. A cknowledgments The authors gratefully acknowledge Chris Collins, M.S.W., program consultant for Community Care of North Carolina, Shelley Keir in the CCNC central office, and Anne Braswell, senior analyst and HealthNet program manager, North Carolina Office of Rural Health and Community Care, who kindly provided information for the case study. We also thank L. Allen Dobson, M.D., vice president for clinical practice development at Carolinas Healthcare System and formerly assistant secretary in the North Carolina Department of Health and Human Services, and other staff at the CCNC central office who provided feedback on a previous draft of the case study. The authors also thank the staff at The Commonwealth Fund for advice on and assistance with case study preparation. Editorial support was provided by Joris Stuyck. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.