Using Rural Health Networks to Address Local Needs Five Case Studies By Ira Moscovice, Ph.D., and Walter Elias, Ph.D. July 2003 About AcademyHealth decision-making in state government and rural health delivery systems. Dr. Moscovice received AcademyHealth is the professional home for his Ph.D. in operations research from Yale health services researchers, policy analysts, University. and practitioners, and a leading, non-partisan resource for the best in health research and Walter S. Elias, Ph.D., is founder and presi- policy. AcademyHealth promotes the use of dent of Elias & Associates, Inc., which pro- objective research and analysis to inform vides strategic planning, research, and prod- health policy and practice. uct development support to businesses work- About The Robert Wood Johnson ing in the areas of health promotion, and dis- ease and demand management. Dr. Elias Foundation received his Ph.D. in anthropology from the This publication was produced under University of Pennsylvania. AcademyHealth’s Networking for Rural Health project, which is made possible by a grant Acknowledgments from The Robert Wood Johnson Foundation The authors would like to thank the following (www.rwjf.org). Based in Princeton, N.J., The individuals for their contributions to this Robert Wood Johnson Foundation is the report: Dan Campion, William Diggins, nation’s largest philanthropy devoted exclusive- Christina Folz, Murray Frank, Gerald Messana, ly to health and health care. It concentrates its Mark Roisen, and Debra Williams. grantmaking in three goal areas: to assure that all Americans have access to basic health care About this Series at reasonable cost; to improve care and support This collection of case studies is the final docu- for people with chronic health conditions; and ment in a series of eight written products creat- to reduce the personal, social, and economic ed by the Networking for Rural Health project. harm caused by substance abuse. Other monographs focus on the principles of About the Authors rural network development, strategic planning, business planning, shared services, quality Ira S. Moscovice, Ph.D., is a professor in the improvement, and legal issues for rural net- Division of Health Services Research and Policy works. For more information, visit www.acade- at the University of Minnesota. He is a co-project myhealth.com/ruralhealth/index.htm or contact director of the Networking for Rural Health proj- Dan Campion at 202.292.6700. ect and has written extensively on the use of health services research to improve health policy Introduction Rural health networks have captured the attention of 2. The Lac qui Parle Health Care Network (p. 10) health care providers and policymakers as an impor- includes three hospital-based systems that pro- tant strategy for improving access to health care vide services to the 15,000 residents of its three- services for rural populations, increasing the effec- county service area in the southwest central tiveness of network member institutions, and aiding region of Minnesota. The targeted consultation the diffusion of managed care in rural areas. assessed the feasibility of developing satellite Networks bring together rural providers—and possi- primary clinics and implementing shared emer- bly other agencies, employers, or community organ- gency room call coverage. izations—to address health care problems that could not be solved by any single entity working alone. 3. The Maine Health Alliance (p. 16) consists of 11 The aim of the Networking for Rural Health project, community hospitals and 350 medical practices a recently completed three-year initiative of The in five northeastern counties of Maine. The net- Robert Wood Johnson Foundation, was to strength- work’s service area has a population of 325,000 en the rural health care infrastructure by fostering dispersed over 15,000 square miles. The targeted development of rural health networks that seek to consultation was used to help develop the case improve access to and the quality of health care serv- management software needed to implement dis- ices in rural communities. ease-management protocols. The purpose of this monograph is to present five 4. The Southwest Texas Network (p. 22) consists of case studies of networks that used the resources pro- five non-profit, federally qualified health centers vided by the Networking for Rural Health project to serving 10 medically underserved counties in south plan and implement activities to meet community central and southwest Texas. The targeted consulta- needs. These case studies highlight a range of net- tion was used to develop the foundation for a cor- work sizes and compositions, service area character- porate compliance program. istics, and relevant activities. 5. The Upper Peninsula Health Care Network (p. 35) The networks profiled in this report are among 27 includes a regional medical center, 13 community that received targeted consultation grants through hospitals, a tribal health center, and a behavioral the Networking for Rural Health project (see health provider network. The Upper Peninsula of Appendix on p. 39 for a complete list of grantees). Michigan spans 16,600 square miles with a popula- The networks used the funds to engage consult- tion of 318,000 residents. The targeted consultation ants, who provided assistance on legal, actuarial, addressed the shortage of hospital coding personnel communications, and procedural issues. Using in the region. Robert Wood Johnson Foundation funds, the proj- ect provided each network with up to $40,000, For each case study, we used reports prepared by which the network matched dollar-for-dollar. consultants, interim and final reports prepared by the network director, relevant secondary data pro- The following networks were profiled in this report: vided by each site, and reports prepared by project staff. In addition, we conducted extensive phone 1. The Dukes County Health Council (p. 2) has 32 interviews with the network director at each site. members representing the key health care stake- holders on Martha’s Vineyard, Mass., including Each case study includes the network’s history and consumers, providers, businesses, elected offi- background, a description of the objective of the tar- cials, and the Wampanoag Tribe. The island has a geted consultation, and the progress the network year-round population of 16,000, which increases has made in reaching their goals. The case studies to 90,000 in the summer with tourism. The tar- also detail implementation challenges, post-grant geted consultation was used to support the plan- activities, the potential for replicability, and lessons ning and analyses for developing a health care learned. We hope these case studies will interest plan, including a health insurance component, for rural health care leaders as they strive to improve low-income island residents. their understanding of how the collaborative efforts can address local needs. 1 Dukes County Health Council: A Community-Based Health Plan for the Uninsured and Underinsured Dukes County Health History and Background of Network Health Insurance Survey Council members The Dukes County Health Council is a 32- In late 1998, Massachusetts conducted a The Council is a broad-based coali- member group that was appointed by the statewide health insurance survey that was tion of consumers, health care prac- Dukes County Commissioners in 1996. It administered by the Center for Survey titioners, health care organizations or facilities, and government offi- represents the major health care constituen- Research (CSR) at the University of cials. As of June 2003, there were 35 cies on Martha’s Vineyard, Mass., including Massachusetts. The Council was able to active members. health care consumers, providers, business- secure funding to supplement the University es, elected officials, and the Wampanoag of Massachusetts survey by including 500 x Practitioners include a family physician, a chiropractor, a tribe. The principal goal of the Council is to Martha’s Vineyard households. The survey psychiatrist, a psychologist, improve health care and wellness for all created a rich database about health insur- a mental health counselor, a island residents, especially those who are ance and health services needs of both dentist, and an emergency uninsured or underinsured. With its econo- insured and uninsured island residents. The medical technician. my based largely on tourism, Martha’s results indicated that 3,000 (19 percent) of x Health care organizations Vineyard has one of the highest percentages the 16,000 year-round residents had no represented include the local of uninsured in Massachusetts, approximate- health insurance, and 80 percent of the hospital, hospice, and visiting ly 20 percent, compared to a statewide per- uninsured were employed. nurse service, and the Island centage of approximately 7 percent. The Health Plan. island has a population of 16,000 (90,000 This finding, coupled with the high cost of x Community organizations or from May to September). health insurance for small businesses on the social service agencies include island, became the key motivation for develop- an elder services organization, Although Martha’s Vineyard has an image of ing the Island Health Plan (IHP). Members of chronic care network, NAACP, catering to the rich, many of its year-round the Council generally agreed that the number AIDS alliance, and a local residents are employees in the tourism of uninsured and underinsured people on the church. industry who cannot afford health insurance. island was unacceptable, and that ways to x Government officials include the More than 80 percent of small businesses improve their access to affordable, timely, and county commissioner, associate on the island do not provide coverage. Most appropriate health services should be a priority commissioner for elder affairs, island businesses have fewer than 10 for the network. associate commissioner for affairs concerning handicapped employees and don’t offer medical benefits. persons, chief of police, public Median income is $44,000, and the cost of Consulting Project schools representative, and an living is 15 to 20 percent higher than on the In December 1998, the Council decided to all-county selectman. mainland. engage the services of a consultant to assist in x Other members include a retired the development of the IHP. The network attorney, a high school student, In 1998, the Council decided to concentrate selected John Snow Inc. (JSI). The contract and the executive director of The its efforts on developing a health plan, and project work began in July 1999. The Foundation for Island Health. including a health insurance component, consultant’s goal was to help the Council to that would improve residents’ access to high define and develop a health plan, including quality, affordable health care. The Council Service Area health insurance, for all residents of Martha’s Dukes County, Mass. envisioned a plan that would respond to the Vineyard. The project had three phases: (Martha’s Vineyard) needs and preferences of island residents, was open to all those who chose to partici- Phase I (Feasibility)—to determine whether pate, and was planned and managed by the it was realistic for the Council to proceed community. The decision to focus on health with its goal of developing the IHP, and, if insurance as a mechanism to improve access so, to decide which options or models for the was based on information that a large pro- health plan were most attainable; portion of island residents were uninsured or underinsured. 2 Phase II (Planning)—to determine the spe- Martha’s Vineyard Hospital (MVH) was fore- cific steps that the Council should take in most in people’s minds when issues of developing the health plan; and health care were raised. While opinions were diverse, everyone agreed that the plan would Phase III (Implementation)—to assist in need to address perceived problems in the making the health plan operational. hospital as well as reinforce its positive attributes. Several years ago, the hospital fell Phase I (Feasibility) into bankruptcy and had routinely posted significant Emergency Room (ER) losses. The feasibility phase of the project took place The ER sees about 14,500 patients per year, between July 20 and October 31, 1999. The and the number has been growing with the specific objectives of this phase were to: influx of retirees and Brazilian immigrants x Define critical health care and insurance to the island. To deal with the immediate ER issues on Martha’s Vineyard that affect the deficit, $500,000 were raised from local components of the IHP; property taxes. x Assess the willingness of various Managed care was not widely accepted as a constituencies (consumers, providers, reasonable means of providing quality, employers, and community leaders) to affordable health care. Health care providers support and participate in the plan; were particularly resistant to this approach. x Determine the number of people likely to Access to off-island health care services was enroll in the IHP, and describe their an important priority for many island resi- characteristics; dents. Reasons that people seek services off- x Describe which benefits should be island include an expanded choice of part of the plan; providers, the need for services not offered on the island, confidentiality, requirements x Define the cost of the plan and the of their current insurance plan, and percep- potential for controlling costs; tions that quality is higher elsewhere. x Describe key issues that could affect the success of the plan; and Phase I was completed, and the following x Provide recommendations on the design recommendations were presented to the Council in November 1999: of the plan, including options. The feasibility study phase included: x The Council should play a leadership role in developing a health plan for the island. x Key informant interviews with x The Council should continue its constituencies, including members of the Council, consumers, health care and social multifaceted approach to improving access service providers, elected and appointed to quality, affordable health care to all officials, employers, insurers and insurance island residents; and agents, and community leaders; and x The Council should focus its initial efforts x Data analysis, principally focusing on the on developing a health insurance program Martha’s Vineyard Health Insurance that targets groups who are at a disadvantage Survey, census data, employer/employee in the current insurance market. data, and information on selected health insurance plans offered on the island. 3 Phase II (Planning) to keep down the cost of their plan, includ- ing self-funding and, especially among small The goal of Phase II was to prepare the employers, frequent switching of carriers to IHP for implementation through further obtain the best price. The lowest monthly planning using surveys and focus groups. premium for a large employer on Martha’s The Council was awarded a targeted consul- Vineyard (used as a benchmark for the best tation grant under The Robert Wood premium possible under an island-spon- Johnson Foundation’s Networking for Rural sored health plan) was $250 per individual Health Project. The award totaled $32,500 and $550 per family. Cost was the major rea- to match funds already raised from the son that employers did not offer health Massachusetts Medical Society, local banks, insurance. Employers had little or no knowl- and foundations. These monies were used edge that state subsidies were available for in part to pay for an additional year of con- some small businesses. sultation by JSI to implement Phase II (Planning) of the project. The majority of uninsured individuals were employed adults under age 65. With high JSI conducted four focus groups in March health insurance rates, many islanders were and April 2000. Participants included small left to pay more than their wages could sup- employers, self-employed individuals, or port. This created a great deal of anger uninsured people. The purpose of the among employees who were working hard groups was to: and paying taxes but struggling to be taken care of medically. The situation led to sig- x Determine reasons for not offering or nificant health care utilization by the unin- purchasing health insurance; sured, including costly emergency room x Assess what is considered an “affordable” visits. While nearly 90 percent of people premium; who were uninsured said they could pay x Determine which benefits and coverage something toward the cost of coverage, most would need a significant subsidy. were desired in an island health insurance plan; Factors influencing employers’ decisions to x Assess providers’ and consumers’ not offer health insurance included: receptivity to the concept of the IHP, and identify factors that would influence x The seasonal nature of many jobs providers’ and consumers’ decision to on the island; participate in such a plan; and x An inability to meet the eligibility x Determine the familiarity of participants and participation requirements of with, and potential eligibility for, state- insurers; and sponsored health coverage—in particular, the Insurance Partnership and Family x The lack of a competitive disadvantage Assistance Programs, which make state associated with failure to provide health subsidies available to small employers insurance. and low-income workers. Most participants had no familiarity with the new state premium subsidy programs, Health Insurance Issues suggesting the need for additional market- Employers on Martha’s Vineyard offered a ing to small employers. Although support- wide variety of health insurance plans to ive of the concept of the IHP, employers their employees. They used many methods said they would use the same criteria to 4 make decisions about whether to offer such Actuarial Analysis a plan as those used by employers that now Data collection efforts during Phases I and offer insurance, namely cost, scope of bene- II focused on current health insurance cov- fits, and provider network. In addition, sup- erage, insurance purchasing practices, and port of the island’s physicians was seen as health care use patterns of island residents critical to the success of any island health and employers. Reden and Anders, Ltd. insurance plan. (R&A), a nationally recognized health care actuarial firm, developed per member per A short written survey was mailed to ran- month (PMPM) revenue requirements for domly selected island businesses. The sur- the IHP, assuming two target populations: vey sought to identify whether employers were able to offer health insurance to their x The “commercial” population comprised employees, and, if so, the details and cost of of those individuals who were employed that coverage. It also inquired about barriers (people with incomes above 200 percent to furnishing coverage and employers’ will- of the federal poverty level [FPL]); and ingness and ability to fund this benefit. x The “Medicaid-like” population comprised of those individuals who are unemployed Survey results showed that almost two- but not eligible for state programs (people thirds of employers do not offer health with incomes less than 200 percent FPL). insurance, with three-quarters of them employing fewer than five workers. Overall, For the Council to make informed decisions small firms were less likely to offer health about pricing the health plan premiums, insurance. Businesses that offered health R&A was asked to find a balance between insurance usually made it available to full- premiums, reimbursement, and state subsi- time, year-round employees. However, only dies for low-income residents. In an effort to 20 percent of these employers offered make premiums for the IHP more affordable health insurance to their part-time workers, to enrollees who met income criteria, the and only 8 percent of them offered it to Council proposed to reduce the provider fee their seasonal workers. schedule based on consumers’ income level. The only difference between the two target As with the focus groups, most survey populations was the level of reimbursement respondents identified cost as the major rea- provided to individual physicians. PMPM rev- son for not providing health insurance. enue requirements obtained from R & A Most significantly, almost two-thirds of were translated into premium rates based on employers were not willing or able to con- standard actuarial methods. tribute a significant amount toward insur- ance premiums. Last, all employers Survey and focus group results showed that appeared receptive to offering the IHP if it 70 percent of consumers could only afford became available. Factors that would con- to pay $100 each month for health insur- tribute to employers’ decision to offer the ance coverage. Only 35 percent of employers IHP included: the plan’s cost, the insurer’s surveyed were willing to contribute anything financial stability, as well as the covered toward employee coverage, with 50 percent benefits, including access to off-island of this group willing to pay less than $100. providers. Combining the lower physician reimburse- ment rates and state subsidies with the $100 contribution from both consumers 5 and their employers closed the affordability A regional consortium of groups from Cape gap for all individuals and for two-person Cod and Nantucket, including the Council contracts with incomes less than 400 per- and the Lighthouse Health Access Alliance cent FPL. (LHAA), applied for a Community Access Program (CAP) grant funded by the Health Still, a significant gap remained for family Resources and Services Administration. Over a contracts at all income levels (for a family of three-year period, the LHAA was awarded four, 200 percent FPL = $36,800; 400 per- approximately $1.7 million that grew to $2 mil- cent FPL = $73,600) and for two-person lion with local fundraising. These grant funds contracts for consumers with incomes were used to fund one FTE working on devel- greater than 400 percent FPL. Given the opment, two of four part-time employees, part area’s extremely high cost of living, low of the Council office rent, and the use of JSI income is defined as up to 400 percent FPL. for Phase III of the IHP. However, employees with families may not require a family contract, as their children Supported and staffed by the LHAA starting may qualify for coverage under the in July 2002, the Island Health Plan, Inc., a Children’s Medical Security Plan (CMSP). newly formed 501(c)3 corporation, in coopera- Although the CMSP does not offer inpatient tion with the Commonwealth of Massachusetts coverage, the Council will attempt to struc- Division of Medical Assistance (Medicaid) and ture a wrap-around policy for children cov- an insurance partner, the Neighborhood ered under the CMSP, in the event that they Health Plan of Boston, is preparing to launch a are hospitalized. Whether the IHP can be new health plan for low-income island resi- made affordable depends on whether dents in summer 2003. employers are willing to assume responsibil- ity for at least half of the cost of employees’ Phase III (Implementation) health insurance coverage, and whether the Phase III of the project was designed to provider community is willing to accept dis- implement the IHP. JSI developed a com- counted reimbursement rates. prehensive business plan and budget for the implementation phase, which the Council An example of cooperation between the approved. Council and MVH was their joint effort to seek a primary care Health Professionals Business Plan Development Shortage Area (HPSA) designation, which the island received in fall 2002. Qualifying the The business plan had three components: Vineyard as a federally designated HPSA will strategy, analysis, and implementation. create opportunities to improve primary care access. The HPSA designation makes the The strategic and analytic components of the Vineyard eligible to recruit providers through business plan included the short- and long- the National Health Service Corps, which term goals of the IHP, the key components of offers loan forgiveness to providers practicing the plan, and the structure of the insurance in designated underserved areas. In addition, program, including definition of the relation- the HPSA designation allows providers who ships with insurance partners and/or TPA. employ a nurse practitioner or a physician The analytic component of the business plan assistant to pursue certification as a Rural included costs, utilization, and revenue pro- Health Clinic (RHC). This certification jections for the IHP and any other proposed enables providers within the RHC to receive services. The estimates were based on the cost-based reimbursement from Medicare information collected in the focus groups, and Medicaid. employer survey and analysis of the Massachusetts State Insurance Survey, and actuarial analysis of costs and utilization. 6 Progress to date in Phase III NHP revolved around their experience The following progress has been made in working with CHCs around the state as the implementation phase of the project: well as their understanding and interest in the island’s uninsured situation. With x A series of group and individual modest offices and “real staff,” they were a natural fit for the Council. meetings with providers—particularly primary care physicians—was x NHP also has a contract with the state conducted to address questions and Medicaid program with a negotiated concerns about the IHP, elicit support, capitation rate. Local physicians are likely and lay the groundwork for developing to encourage islanders to enroll in participation contracts. A long-term goal NHP’s Medicaid program since it means of the IHP is to form a Community less paperwork for them and slightly Health Clinic (CHC). Of the eight better reimbursement. primary care physicians on the island, x IHP subsidy sources are being assessed. three are paid by the MVH, and five are The goal in developing the IHP was to independent. NHP has met with each of have a premium that could be covered as them individually. The physicians have much as possible through employer and agreed to join the IHP, and NHP will consumer contributions, and by existing present them contracts shortly. state subsidies. However, it is likely that x The range of insurance benefit options the IHP will need additional subsidies to and premium structures for the IHP achieve 100 percent coverage of people were test marketed with potential wanting to participate. purchasers (employers and individuals) Massachusetts Division of Medical and with insurance brokers. Assistance (DMA) representatives x The benefit and premium rates and suggested that the state might be willing underwriting criteria were finalized. The to explore opportunities to use Martha’s Council’s preferred benefit packages and Vineyard and the IHP as a test site for premium assumptions were presented to making the Insurance Partnership two potential insurance partners, Blue Subsidy program more accessible by Cross of Massachusetts and the changing the subsidy amounts. As a Neighborhood Health Plan. Underwriting result, IHP filed legislation to raise criteria, such as eligibility for the plan and income eligibility to 300 percent FPL on cost-sharing, have been explored. The a demonstration basis and expects to see new plan’s rates will be similar to those passage by July 2003. of other insurance plans available to x MVH’s HPSA designation, along with islanders. It is estimated to cost approxi- the Critical Access Hospital designation, mately $270 for an individual and $750 for make the Vineyard potentially eligible for a family each month. However, employer federal programs to address the shortage contributions and outside subsidies will of physicians as well as programs lower the cost that subscribers are paying. offering enhanced Medicaid and x The Neighborhood Health Plan (a Medicare reimbursement. The LHAA Boston-based affiliate of the Harvard will coordinate this activity. Pilgrim Health Plan) was chosen as the x Physicians, brokers/agents, and insurance partner. A memo of employers are being kept informed about agreement with NHP is being created. benefit, network, and marketing NHP will assume all financial risk and decisions related to the IHP. the Council will do the marketing and help maintain the support of island physicians. NHP, whose mission is to serve low-income populations, has 140,000 current members (100,000 Medicaid). Part of the decision to choose 7 x Meetings continue with providers to 2. Continued collaboration with the determine an acceptable level of Division of Medical Assistance to reimbursement (i.e., sliding scale fees) to increase the amount of subsidy ensure provider support of the IHP. The paid and extending the eligibility IHP has received preliminary approval from up to 400 percent FPL; and the state Division of Insurance to conduct a demonstration project of a sliding scale 3. Passage of a $1 million federal co-pay that will meet local providers’ appropriation earmarked for IHP reimbursement thresholds. demonstration subsidy and core budget support. x The Healthwise Handbook, a self-care book, is being distributed at hospital health fairs. x Exploring opportunities to formally designate providers as Rural Health x A Web site is under development. Clinics—which would allow them to receive cost-based reimbursement Spillover Effects for Medicare and Medicaid patients and thus reduce the potential impact The project is receiving national publicity of the proposed IHP fee schedules and is potentially spreading to other parts on net income. of the country. For example: x The IHP director will travel to health x Articles about the IHP have appeared plan sites in Michigan and in the Washington Post, the Boston Minnesota to visit and learn from Globe, and other local newspapers. their CAP project experiences. x The LHAA has received inquiries from x As part of the LHAA’s Year 3 work Florida, Indianapolis, as well as several plan, consultants will help obtain other Massachusetts communities. additional federal and state designations that appear appropriate x The Community Health Leadership in terms of need and geographic/ Network (CAP-affiliated) is profiling demographic criteria throughout the the project for national publicity. region (e.g., Medically Underserved x The Nantucket Council for Human Area, Medically Underserved Population, Services invited the IHP to submit a and Nantucket HPSA); and funding proposal for Fiscal Year x The Health Council is conducting a 2004 for island-wide health retreat to evaluate its future insurance on Nantucket. IHP was direction, and will subsequently also awarded funding to begin a decide what its relationship will be marketing/public relations effort and with the Island Health Plan. provider network formation. Lessons Learned Next Steps The Council learned many lessons The Council still needs to take some throughout its efforts to develop the IHP, important steps prior to implementation, including: including: x All steps have taken longer than x Determining methods for overcoming anticipated. The Council eventually the affordability gap that exists for became more realistic about the amount two-person and family contracts through: of time that certain activities would 1. Local fund raising and eventually require. JSI was a major asset to the (over two to three years) some Council in technical matters (e.g., property tax funding; finding an actuarial firm, training the Council to negotiate with insurers). 8 x The Council was the driving force x The affordability of the plan depends behind formation of the Health Plan. It largely on state and federal contributions, successfully and collaboratively raised physician willingness to accept reduced funds and was a very effective forum for reimbursement, and a potential tax subsidy. issues regarding the uninsured and It also depends on attracting further funding underinsured. from MassHealth if and when the Division of Medical Assistance agrees to lift patient x Data from the University of financial eligibility to a full 400 percent FPL. Massachusetts survey were extremely helpful in highlighting the high cost of x Mental health practitioners are eager to insurance to small businesses and the work with the IHP, as their relationships high percentage of working uninsured. with other managed care organizations have not been satisfactory. They are x As a rural, community-based health interested in putting the IHP’s provider plan, the IHP has led to a possible advocacy commitment to the test. redistribution of power. To date, most of the power has resided with physicians x It is still unclear how many groups will and the hospital. The Dukes County sign up. Many businesses consider Health Council and the regional LHAA themselves seasonal and may not want have created a “ground up” model in the to offer this benefit to off-season IHP. Instead of the government employees. providing universal coverage, these local organizations are forming partnerships Summary among providers, hospitals, insurers, employers, and state and federal The IHP was built on a strong foundation. governments. The IHP was designed Through a rural network that represents a solely to meet community needs and variety of stakeholders, a group of island res- preferences. idents joined together with an insurance partner, set up a network of local doctors and area specialists, reached out to employers x There is, and will continue to be, a and local hospitals, and sought a mix of constant need to balance the financial funding streams, including the federal and aspects of running a business entity with state government, foundations, and local a community health orientation that taxes. Communities elsewhere in the coun- requires subsidies. try have relied on government bodies to coordinate health care and subsidize afford- x Physician reaction ranges from reserved able health insurance through existing funds to cynical to enthusiastic. New models of or special taxes. But on the Vineyard, a close- delivery are being examined, such as knit community where most people know incentivizing physician affiliation and each other’s faces if not their names, resi- participation in group practice or dents organized a grassroots effort to create community health centers. a solution. The IHP will be available to cus- tomers in summer 2003. 9 Lac qui Parle Health Care Network: Improving Local Access to Primary Care Services Lac qui Parle Rural Health History and Background of Network Swift and Yellow Medicine Counties) is Network members characterized by: The Lac qui Parle Health Care Network (LqPHN) was formed as a Management Madison Lutheran Home in x an aging population; Services Organization in 1998 to improve Madison, Minn. access to primary care services and technolo- x an agricultural-based rural community; Johnson Memorial Health Services gies in the southwest central region of of Dawson, Minn. Minnesota. The three members of LqPHN x a group of small rural hospitals that include the Madison Lutheran Home in provide a range of outpatient and long- Appleton Municipal Hospital and Nursing Home of Appleton, Minn. Madison, Minn.; Johnson Memorial Health term care services to meet the needs of Services of Dawson, Minn.; and the Appleton the elderly; and Service area: Municipal Hospital and Nursing Home of x challenges in maintaining access to Appleton, Minn. primary and secondary care services for Lac qui Parle, Swift, and Yellow Medicine Counties in Minnesota local residents. LqPHN members are similar in their struc- ture, services, and service area populations. LqPHN initially focused on providing The Madison Lutheran Home health system professional services to its three includes a hospital, nursing home, rural members that would improve local access health clinic, and attached housing. The hos- by adding a range of primary care pital, which is licensed for 21 inpatient beds, services and technologies at an affordable has expanded its outpatient services in recent cost. In its initial two years of operation, years. The nearest tertiary care center is 60 the network developed the following miles away in Willmar, Minn. Approximately products, services, and programs: 4,300 people live in the health system’s serv- x the group purchase, installation, and ice area, with the proportion of elderly administration of a home health charting increasing. software program, which significantly reduced administrative time in Johnson Memorial Health Service is a hospi- processing reports, billing, and data tal district that includes a hospital, nursing analysis; home, rural health clinic, home health x the purchase and installation of a agency, and ambulance service. In 2001, the regional NOAA weather radio emergency hospital was certified as a Critical Access broadcast transmitter; Hospital. The population in its service area is similar to that in the region serving the x the development of an integrated Madison Hospital. Almost 75 percent of schedule for a portable ultrasound to be inpatient admissions were Medicare benefi- purchased and shared between all three ciaries in 2000. The hospital has recently members; and experienced a substantial increase in outpa- x the coordination of physician and other tient service use. staff recruitment and retention efforts. Appleton Municipal Hospital is a 23-bed Through these early joint efforts, the facility that has an attached clinic, nursing network members built a sense of trust home, dental clinic, and independent living and tasted some financial success. This facility. It is approximately 20 miles away led to more ambitious efforts to improve from the other two hospitals and uses the local access to primary care services. same tertiary referral centers. Two thirds of its admissions are Medicare recipients, and Targeted Consultation the hospital serves a population of 4,500 people plus a prison population of 1,300. In late 1999, LqPHN received a targeted con- sultation grant of $15,000 from the Networking In sum, the three-county service area of for Rural Health project to assess the feasibility LqPHN (Lac qui Parle County and parts of of developing satellite primary care clinics in up 10 to three sites, and implementing shared emer- gency room call coverage between the network’s enues, expense, and capital requirements. members. These initiatives were identified by The operation analysis provided information network members as central to improving on days and hours of operation, staffing, and access to primary care and emergency care serv- reimbursement implications. ices for the elderly population throughout the service area. LqPHN contracted with Larson, Physician demand at the satellite clinics was Allen, Welshair and Company (LAWCO) from estimated using assumptions and tech- Austin, Minn., to complete the feasibility analy- niques developed in two prior studies, one ses. by the Graduate Medical Education National Advisory Committee (GMENAC) and the Feasibility of Satellite Clinics other commissioned by the Duluth Clinic to assess physician-to-population needs. The The objective of the feasibility analysis was to three towns considered as sites for the satel- assess the fiscal viability of satellite clinics in lite clinics were Milan, Boyd, and Marietta. three sites, evaluate operating issues, and Some highlights of the feasibility analyses examine the potential impact of the satellite are shown in Tables 1 and 2. clinics on LqPHN members. The fiscal analy- sis included an assessment of volume, rev- Table 1: Estimate of Primary Care Visits and Inpatient Admissions Milan Boyd Marietta Population Projected 1,368 1,136 739 Total MD Visits 6,834 5,675 3,691 FP/IM 3,440 2,857 1,858 OB/GYN and Peds 1,122 932 607 Specialty Care 2,272 1,886 1,226 Projected MD Need (FTEs at 100% Market Share and Median MGMA Productivity) FP/IM .82 .69 .44 OB/GYN and Peds .26 .22 .14 Projected Inpatient Admissions 148 123 80 Primary Care 89 74 48 Specialty and Other 59 49 32 Estimated Net Revenues from Inpatient Admissions $621,000 $516,000 $336,000 Table 2: Projected Income Statement for One Day per Week Satellite Clinic with PA/NP Year 1 Year 2 Year 3 Net Patient Revenue, Professional Fees $21,840 $43,680 $58,240 Expenses Provider Costs $17,600 $35,300 $35,300 Nursing Staff $3,100 $6,200 $6,200 Space Costs $7,500 $7,500 $7,500 Other $4,700 $9,400 $12,500 Total $32,900 $58,400 $61,500 Potential Net Margins ($11,060) ($14,720) ($3,260) Net Patient Revenue, Ancillary Services $12,500 $25,000 $33,300 Expenses $7,500 $15,000 $20,000 Potential Net Ancillary Margins $5,000 $10,000 $13,300 Combined Profitability—Professional Fees and Ancillaries ($6,060) ($4,720) $10,040 11 The feasibility analyses concluded that it was LqPHN provides management services by fiscally viable to run a satellite clinic that coordinating the responsibilities of the local would be open two half-days per week and governing board and stimulating program staffed with a physician’s assistant, nurse development in wellness and preventive practitioner, or physician. Based solely on health programs. The clinic has three exam professional fees and ancillary services, the rooms, a lab, a nurses’ station, and a waiting clinic would have small losses for two years area. The clinic provides primary care serv- and become profitable in its third year of ices and coordinates immunization and pre- operation. The estimates listed in Table 2 do natal screening programs with local public not include profits from additional inpatient health and social service agencies. One to admissions from the population in the serv- three days’ worth of most common prescrip- ice area of the satellite clinic. tions can be filled at the clinic. When neces- sary, clinic personnel assist with public Planning and Initial Operation transportation arrangements. In its initial of a Satellite Clinic quarter of operation, clinic staff saw four patients per half day. Network members decided to move forward with their plans to open a satellite clinic in Feasibility of Shared Emergency Boyd. The town had been without a medical clinic for approximately 50 years, and the Room Call Coverage nearest primary care provider, Johnson Emergency care is an important function Memorial Health Services, was 13 miles for rural hospitals that often distinguishes away. There was no local access to health one institution from another. The rural services for the elderly and the uninsured EMS environment has special issues to cope living in the area. with, including: x long transport times; The planning process for the satellite clinic included broad support from representa- x subsidies of EMS, often by financially tives of local residents and public officials; struggling rural hospitals; Johnson Memorial Health Services (JMHS); x EMS personnel shortages; and LqPHN; the state Department of Health; county public health and social service agen- x small volume, leading to limited experience cies; and the local EMS agency. The town with specific types of emergencies and high donated a building on the main street of per capita EMS costs. Boyd to house the satellite clinic. The execu- These issues highlight the importance of tive director of LqPHN developed grant pro- the feasibility analysis, which assesses posals to fund the renovation and start-up potential models for sharing emergency costs for the clinic. The U.S. Department of room physician coverage among LqPHN’s Agriculture provided a grant of $112,000 to three hospital members. From 1996 to renovate the building into the satellite clin- 1998, Madison Lutheran Home and JMHS ic. The Southwest Minnesota Foundation spent on average close to $100,000 per provided funds to paint the building and the year. Appleton Municipal Hospital spent Minnesota Department of Health provided approximately $20,000 per year on outside grants to support planning and start-up ER physician coverage. In 1999, Madison costs (e.g., equipment, lighting, and furni- spent $33,000 and JMHS spent $47,000. ture) associated with initial clinic opera- Appleton did not spend any money on ER tions. physician coverage. The largest determinant of these costs has been the availability of The satellite clinic opened its doors in local staff providers. Table 3 shows ER August 2002 and is staffed two mornings physician coverage by LqPHN member hos- per week by JMHS (one morning by a nurse pitals in 2000. practitioner, one morning by a physician). 12 Table 3: Emergency Room Physician Coverage in 2000 Johnson _ Staff MD coverage: 52 weekdays per year (approx. one week/month) + 13 weekends per year (approx. one weekend/month) + backup for PA/NP _ PA/NP coverage: 48 weekdays (one week/month) + no weekends _ Locums cover 13 to 14 weekends/year (assuming 3 staff MDs) Madison _ Staff MD coverage: 80 weekdays per year (every other week) + 13 weekends per year (approx. one weekend/month) + backup for PA/NP _ PA coverage: one PA covers 48 weekdays (one week/month) + 13 weekends per year (approx. one weekend/month) _ Locums cover 13 to 14 weekends/year (assuming two staff MDs + one PA covering ER) Appleton _ Staff MD coverage: 70 weekdays per year (every third week) + 17 weekends per year (every third weekend) _ PA coverage: None _ No locum coverage needed The consultant held interviews with local N implications of difficult winter travel physicians and nurses to discuss the current between sites. ER physician call coverage situation and Using ER logs from each hospital, the net- alternative models for sharing ER coverage. work completed analyses of the overlap in The models for shared ER coverage ER services. When considering Madison and assumed that call coverage during clinic Johnson only, there was service overlap hours would remain the same and during (i.e., patients in two ERs at the same time) weekday nights and weekends would be 1.5 percent of the time, with a corresponding shared among facilities. The interviews sug- figure of 3.7 percent when considering all gested that reductions in call coverage com- three hospitals. Service overlap across all mitments was important to physicians. The three ERs occurred only 0.5 percent of the Madison and Johnson physicians and all time. Service overlap occurred rarely for DONs were generally supportive of the con- major cases (i.e., among patients who were cept of a shared ER model. However, admitted to the hospital or were trans- Appleton physicians expressed some reser- ferred). Most service overlap occurred on vations due to their distance from the other Saturday mornings and other times of the facilities. weekend rather than during clinic hours or weekday nights. It does not appear that serv- The interviews also identified the following ice overlap is a major issue. key operating issues related to shared ER call: The analyses found significant potential sav- N availability of patient records when M.D.s ings in ER locum coverage costs from a from other hospitals were on call; shared ER call coverage model based on the N impact of Saturday morning clinics on costs and number of locum hours required availability for call; and backup PA/NP hours required (see Table 4). These savings could be realized N timeliness of M.D. response; without reducing coverage. ER call coverage N “turf” issues related to caring for patients sharing models also provide some protec- of M.D.s from another site; tion against increased locum provider costs that may occur as physician supply changes N lack of common clinical protocols across in local communities. ERs; and 13 Table 4: Potential Financial Benefits of ER Call Sharing Based on Actual Based on FY 1999 with Hospital FY 1999 Coverage “Standard”* M.D. Coverage Madison $33,200 $67,000 Johnson $45,700 $67,000 Appleton $0 $86,000 *“Standard” M.D. coverage = 52 weekdays + 13 weekends per provider—which represents reductions from current M.D. coverage levels. However, the network could not reach con- Activities that the network has initiated as a sensus about how to implement shared ER result of their strategic plan include: physician call coverage. The barriers identi- x a monthly noon luncheon case study fied earlier (e.g., distance impact on timeli- review series to bring network ness of response, physician “turf” issues) physicians together, discuss clinical and variation in existing physician call cov- issues, and attract new providers; erage contracts precluded short-term progress in implementing a new shared x monthly health information call model for the ERs of LqPHN’s hospital management team meetings with members. The network director is hopeful department heads from each member that this issue will be addressed in the organization; and future as the network matures. x the addition of a new dues-paying associate member hospital and the Additional Grant Activities submission of new grant applications. In addition to the two feasibility analyses, LqPHN was able to use a small portion of Post-Grant Development the remaining funds from the targeted con- sultation grant to hire an outside facilitator The targeted consultation supported devel- from Teamworks International Consulting. opment and operation of the satellite clinic The facilitator conducted a strategic plan- in Boyd. This experience facilitated, either ning retreat with network member medical directly or indirectly, completion of a plan- staff, administrative staff, and boards of ning process for community health centers directors in June 2000. The group devel- in two other communities in the network oped a strategic plan for the next two years. service area. Both of these health centers They identified the following new areas for have become operational. the network to pursue: LqPHN has also assisted with grant writing x a medical and professional staff case for the two Critical Access Hospitals in the network. One grant was received from the study/journal review group; Minnesota Rural Flex Grant Program of the x development of a Web site for marketing state health department to improve patient and staff recruitment; care through better communication between local medical staffs and regional x cross-coverage staffing; and radiologists. The grant helped network x coordinated scheduling of specialty members with the group purchase of digi- provider groups. tal dictation software and equipment, the development of a coordinated schedule LqPHN members also agreed to support between network members designed to the fiscal viability of the network by charg- handle increased volumes of dictation, and ing annual membership dues of $7,500. the design of new policies and protocols to 14 administer the new system for managing On the other hand, the sharing of emer- transcription staffing. These accomplish- gency room call coverage is a riskier activ- ments were important first steps toward ity. It involves clinical issues related to standardizing medical records, staffing caring for the patients of other physi- procedures, and protocols across network cians, the comparison of clinical proto- members. cols, and coordination of patient records. It is not surprising that a shared ER call Although the anticipated transcription vol- model was not implemented, even ume increase has not materialized due to a though the feasibility analysis estimated shift in policy by the regional radiology that there would be significant savings in group, the Flex grant provided an opportuni- locum physicians’ coverage costs. The ty for collaboration among network mem- network was not mature enough in its bers. This led to another collaborative appli- development to sustain that type of activi- cation for Flex grant support for staff train- ty. In addition, with the advent of cost- ing of coders at JMHS. based reimbursement for the two Critical Access Hospitals in the network, the envi- Lessons Learned ronmental context for these facilities was relatively positive in the short-term. A major lesson that LqPHN learned throughout this project is that rural What, then, will it take for the members health networks cannot be developed of LqPHN to reach a level of integration quickly and need a substantial amount of that will include core clinical activities? time to mature. LqPHN had some initial Key factors will likely include strong net- successes with limited-risk activities such work leadership, continued building of as the group purchase and use of a home social capital among local providers and health charting software program and a residents by completing ongoing activi- portable ultrasound machine. The target- ties, physicians who understand the costs ed consultation led to the successful and benefits associated with network par- development and opening of a satellite ticipation, environmental threats posed by clinic in a small rural community. weakened federal, state, and local economies, and population declines. The clinic improves access to primary Rural health professionals, institutional care services for the elderly in the area, leaders, and policymakers clearly need to although patient volume is lower than the make a long-term personal and financial projections used by the consultants in the commitment to networks like LqPHN if feasibility analysis. Two other satellite they want such entities to address com- clinics have since opened in the service munity and provider needs. area. Although these clinics may yield modest economic return for their host institutions, their principal benefit is improved primary care access. 15 Maine Health Alliance: Fostering Care Management in the Rural Environment Maine Health Alliance members History and Background of Network are not available. In addition, current reim- bursement strategies do not provide for the Calais Regional Hospital In 1995, representatives from 11 community post-discharge health care services that are Calais, Maine hospitals in northern Maine formed the necessary for optimal recovery. This pattern Maine Health Alliance (MHA) in an effort to Cary Medical Center of resource utilization greatly escalates the Caribou, Maine prepare themselves for an increase in man- cost of health care. aged care penetration in the state. In addition Down East Community Hospital to the 11 community hospitals, the network Machias, Maine A care management initiative was designed to: includes 350 medical practices. Its service Houlton Regional Hospital area spans the five most northeastern coun- Houlton, Maine ties of Maine (Aroostook, Hancock, 1) Coordinate and manage health care Penobscot, Piscataquis, and Washington), services for patients with chronic health Maine Coast Memorial Hospital conditions; Ellsworth, Maine with a population of 325,000 spread over 15,000 square miles. The median age in the 2) Achieve better outcomes; Mayo Regional Hospital Alliance’s service area is older, and the popu- Dover-Foxcroft, Maine lation’s health status worse, than that of both 3) Reduce utilization of emergency Millinocket Regional Hospital Maine and the United States. Medicare repre- department and inpatient services; and Millinocket, Maine sents approximately 50 percent of patient- care revenues of community hospitals in 4) Improve patient satisfaction and Mount Desert Island Hospital Bar Harbor, Maine northern Maine (Medicaid represents another compliance. 10 to 15 percent). Northern Maine Medical Center Fort Kent, Maine In 1999, the MHA was awarded a Federal The MHA aims to preserve local access to Office of Rural Health Policy Outreach grant Penobscot Valley Hospital health care by helping its members maintain to secure care management personnel, equip- Lincoln, Maine financial viability, avoid contract exclusion, ment, and supplies for the three hospitals in and provide the highest quality care to con- Aroostook County. Houlton Regional St. Joseph Hospital Bangor, Maine sumers. Governance in the Alliance is shared Hospital had administrative authority over equally between hospitals and physicians. the project. Houlton, along with Cary Medical Plus 350 medical practices Approximately 60 percent of Alliance doctors Center in Caribou and Northern Maine are primary care physicians. The MHA holds Medical Center in Fort Kent, provided care Service Area 21 payer contracts and is included by all sig- managers, patient referrals, and clinical serv- Aroostook, Hancock, Penobscot, Piscataquis, and Washington counties nificant payers. It plans to continue to pro- ices. The MHA, as a provider network PPO, mote the financial viability of its members provided a link between these Aroostook through payer contracting and joint cost-con- County network providers and providers of tainment efforts. The network is developing specialty and tertiary services in Bangor. care management capabilities in order to per- form better under risk-based contracts The project lacked the care management soft- through the provision of disease manage- ware needed to implement disease manage- ment programs. ment protocols. The network found that com- mercially available software was either too Care Management Program expensive and/or did not address the unique Patients with chronic conditions living in needs of the rural patient population. To rural areas of Maine often must cope with address this, the network sought a targeted limited access, inadequate transportation, consultation to help develop the necessary and financial constraints. As a result, existing software. It was awarded $35,000 from the resources are often manipulated to meet Networking for Rural Health project for plan- their health care needs, such as ambulance ning and initial implementation. service for non-emergent transport to emer- gency rooms when primary care providers 16 Several consultants were engaged for this The development of rural-oriented care man- work, including: agement software allowed care managers to systematically monitor high-risk or high-uti- x Providia Healthcare Group (general lization patients on a prescribed basis using contractor, strategic planning); uniform care management processes. Diagnosis-specific protocols, developed as x Kelsey Healthcare Solutions (consulting part of the software, are being employed, but nurse for disease and case management); the software provides the capacity to tailor x VeARD Computer Research, Inc. (develop- protocols to the needs of specific patients, ment, testing, implementation, training, physicians, or medical staff. Rather than hav- and maintenance of Web-resident disease ing fixed protocols, the care manager has the management software); and discretion to modify a particular care man- agement plan based on unique circum- x Lisa Clark, Esq., of Duane, Morris & stances. The software was specifically created Heckscher, LLP (analysis of HIPAA to extend beyond “silo” disease management, regulations). since 40 percent of people with the top seven Web-based software was created for an outpa- major chronic illnesses have three or more tient care management program addressing diagnoses. chronic health care problems such as chronic obstructive pulmonary disorder, diabetes, Referrals began coming into the program asthma, and heart disease. The population to from physicians who wanted care manage- be served included the elderly, minorities, ment follow-up for patients upon hospital children, and people with disabilities. discharge. Not long into the project, the Currently, four hospitals in the network are physicians began referring to care manage- using the software and one is in training. ment services from emergency rooms. As a Three of the 11 hospitals began providing result, care managers are now receiving care management services under an outreach referrals directly from physicians’ offices. grant from the 1999 Federal Office of Rural This has been a major accomplishment with Health Policy. Two of these were providing the intent to apply services to appropriate this service prior to the 1999 initiation of the patients well before they require inpatient federal grant. They did so based on the belief services. The incentive for physicians to use of leading local physicians that care manage- the program (all admissions to the program ment would improve care. The hospitals were require a physician’s order) is clearly a moti- motivated to do so especially for their vation toward improved medical care. Medicare population because of high read- Others in the community can refer patients mission rates before these chronic care to the care management program, but, as patients’ DRG would “reload” (i.e., be author- noted, admission requires a physician’s ized for a new payment). order. Fundamental to the program is the intent that a referral to care management Two community-based disease manage- will improve patient care, most notably ment/care management applications are cur- through improved patient compliance with rently operational. The first uses Pfizer’s dis- physician orders. ease management software from the Maine Cardiac Health Committee’s (MECares) pro- Due to better pharmaceutical control, many of gram on congestive heart failure. The second the issues that the care managers deal with are stems from the Office of Federal Rural psychosocial rather than clinical. It is impor- Health Policy outreach grant targeting specif- tant for care managers to be in the community ic patients with chronic diseases. Patients so that they are aware of local community who physicians believe could benefit from resources and can better deal with the psy- outpatient care management were the tar- chosocial issues people in a given area face. gets. This program is using the software Local care managers have an appreciation for developed by MHA with the assistance of what it is like to live in an isolated community AcademyHealth. in rural Maine, while a disease manager from an urban area may lack this understanding. In 17 one example, a man in respiratory distress was on a quarterly basis for the remainder of the burning treated wood that he took from a local grant period. lumberyard. Because his care managers understood the local environment, they were The collection of baseline information was able to identify the treated wood as the cause difficult due to the use of a wide variety of of the condition. data collection approaches among the partici- pating hospitals. Agreement on uniform data Another important factor is the multi-genera- collection methods was reached while devel- tional nature of Maine’s rural workforce. It is oping the content for the care management not uncommon for three generations of a software. The consortium provided a mecha- family to be employed in the mills. If the nism to compare, share, evaluate, and modify grandfather and the father had a history of its disease management model in different heart disease, the care manager will most hospital settings. likely already know about it. The need for a physician champion became RNs and social workers work as a coordinat- evident when comparing provider participa- ed team to cover both the medical and social tion in care management services between aspects of care management. This facilitates a facilities with and without strong physician smooth referral and follow-up process. Care advocates. This issue was addressed through managers are available for a wide variety of ongoing physician contact and education services depending on a patient’s individual efforts and, as the project demonstrated its needs. For very difficult or complicated cases, value, through patient successes. Strong care managers are available to attend medical physician support was also critical to the con- appointments to assist patients in under- tinuation of the care management project standing and complying with their physi- after the grant ended. cian’s orders. In some cases, the care manag- er is also available to act as an interpreter for Internet connectivity is a problem in rural areas patients who speak limited English. without access to dedicated cable lines. To help address this problem, the MHA secured local The care management services provided by foundation funding that helped rural member this project became a cooperative effort among hospitals to significantly improve Internet con- health care providers, patients, and communi- nectivity by the end of 2002. ty support services. This joint effort facilitated patient education and compliance by encour- The division of one FTE care manager posi- aging patients to take more control and tion between more than one person created a responsibility for their personal health care. problem with lack of staff continuity and Because of this sense of participation, patients availability to patients. There was a signifi- felt more secure knowing they had a hospital cant amount of unexpected patient contact. If contact to call when questions came up or a care manager was not available when a resources were needed. Patients felt that the problem arose, a lack of service continuity hospital sincerely cared about them and how resulted. In addition, the patient-care manag- they were doing. Family members who were er relationship is critical for ongoing support not living close-by were relieved to know that and medical compliance. someone was checking in on their loved one. Patient satisfaction data were inadequate for Management, Operation, and pre- and post-service comparison. The MHA Implementation Issues director reported that, rather than asking for a rating of current level of satisfaction, both sur- The oversight committee met on a quarterly veys should have asked patients to identify their basis with the project director and staff to expectations for care management services and review, evaluate, and modify activities or pro- then asked for opinions on how well their cedures as necessary. Care managers from expectations were met. Data should have been the three hospitals met on a monthly basis at collected to track how often patients contacted the beginning of the project. The care man- the care manager, in addition to how frequently agers and a representative of the MHA met the care manager contacted the patients. 18 Results It is possible that reductions in admissions, hospital days, and emergency room visits System-wide outpatient care management were due to regression to the mean rather proved effective in maximizing preventive than care management. There was no control care, controlling utilization of emergency and group in this project. However, all results inpatient services, and effectively coordinat- tend to be in the same direction toward a ing the utilization of care for a chronic dis- reduction in utilization. ease population with complex medical and social needs. The successful implementation of this project demonstrated the need to Lessons Learned establish and expand care management serv- The new care management software and ices to a broad rural population. Web site have integrated the collection of sta- tistical data into the care management The care management software and related process. The data component needed to be Web site were a huge success. The capacity to computerized. Manual collection of data is compile and analyze data, run reports, and given to misinterpretation by care managers produce outcome data has great potential for and is very time consuming. Evaluation sta- demonstrating to local industry and insur- tistics are critical for marketing the project to ance carriers the ability to improve patient doctors for program referrals and for promot- care while reducing unnecessary utilization. ing care management to payers for potential reimbursement. The hospitals worked together very well. Innovative ideas and creative problem-solving Physician education efforts were more effec- strategies were shared to the benefit of all. A tive once the project could demonstrate posi- cooperative alliance was formed and is tive results. Physician reluctance to refer to expected to foster good working relationships the care management project was addressed between the organizations and care man- on a physician-to-physician level. agers for years to come. Limited support resources in rural Northern One of the fallacies of managed care was the Maine was a serious problem, especially in physician gatekeeper. Under the managed the first year of the project. A shortage of care system, physicians had little oversight or nursing home beds and home care providers follow-up of chronically ill patients between was critical. This issue was addressed office visits. A systematic tracking of these through group and individual meetings to patients by care managers improved patients’ inform area providers of the program and its compliance with doctors’ orders, leading to services. When new care managers were better management of various disease hired, they were introduced to community processes, and less reliance on emergency organizations. The relationships formed room and inpatient services. through these efforts resulted in a much more proactive and mutually beneficial col- Participating physicians were very satisfied. laboration, such as nursing homes with open The doctors appreciated having non-clinical beds contacting care managers. issues addressed by a trusted staff member who would alert them to important patient The MHA director reported on some addi- issues and concerns. The doctors also noticed tional lessons learned after going through a significant decrease in patient-related social this software development effort. He advised issues demanding their attention. The care others taking on such software development managers often handled these issues even projects to double their original cost esti- before the physician sought their assistance. mates. He also felt it was critical to hire an intermediary to facilitate communication Care management services had a significant between clinicians and data staff, who have impact on hospital readmissions and emer- differing languages and cultures. The most gency department visits for the target popula- obvious lesson, he said, was to let the people tion (see Tables 5 and 6). who will ultimately use the software for patient care guide its development. 19 Table 5: Services/Utilization Data for the Management Project The timeframe for this services/utilization data is from September 1999 through August 2002. Combined Hospital Percent Total Decrease Original caseload * 59 Number of new cases 485 Cases discharged 295 New referrals 885 Number of patient/family contacts 9,810 Number of physician contacts 1,586 Hospital admits baseline 326 Hospital admits post-care 156 52% management Hospital days baseline 1,115 Hospital days post-care management 525 53% ED visits baseline 269 ED visits post-care management 210 22% *The original caseload is in reference to the pre-existence of case managers with caseloads at two of the Alliance hospitals before the federal grant. Table 6 Hospital Readmissions For Same Diagnosis Within 15 Days Within 31 Days Baseline 5.7% 9.6% Post-care management 2.3% 2.8% MHA began providing care management Diminished reimbursement for home care- services in some of their hospitals for two related services is one crucial consideration primary reasons. First, the physicians felt that for the replication of this project in other it was common sense that these activities rural communities. In recent years, third- would improve patient care. Second, these party reimbursements have focused on capacities were developed in anticipation of reducing home health care costs, making it managed care risk contracts. It seemed illogi- difficult for small rural hospitals to finance cal that providers should take on actuarial care manager positions. risks without developing community-based capacities that could be relied on to affect uti- A community’s unique political climate lization. The full-blown risk contracts never should be considered when setting up a care materialized, but the Alliance’s efforts have management program. Community-based strongly improved patient care and patient service providers were needed to provide compliance and, thus, clinical outcomes. support such as transportation, Meals on Wheels, and visiting nurses, but some com- Application to Other Rural Areas munity agencies were concerned that the care managers would cross service bound- The MHA’s care management model should aries to impact their funding or service area. work well in rural settings where there is a commitment to its success by the hospital’s Project leaders can expect results to look physicians and administration. The care more impressive in the beginning. Once the management software, because of its flexibili- program has a good track record with seri- ty and Web site usage, makes this project ously ill patients, physicians will start refer- especially appropriate to rural settings. 20 ring patients with less severe problems. stration project, ME-Cares, in the state of There will be less opportunity for cost sav- Maine. The MHA believes that care manage- ings with these patients. ment may someday become a reimbursable service under Medicare. In the meantime, The care management software product is they will struggle to find known sources of replicable in other rural environments. Other payment for these services. hospitals within the Alliance have begun using the software. The MHA would be inter- Anthem Blue Cross in Maine has begun to ested in selling the software to another focus on the 5 percent of their enrollees who provider. However, much of the software con- use 55 percent of their premium revenues. tent belongs to the company that helped cre- They are considering community-based dis- ate the application. The Alliance has not ease management offered by the Alliance. established a fee for using the software, but, They currently have two national disease if the request came from outside of the management vendors in place. MHA is reim- Alliance, they would respond. As the Alliance bursed under the ME Cares program on a is not in the software sales business, their per member per month basis. CIGNA reim- price would be minimal. (This represents the burses on a per member per month basis for point of view of the MHA and not the soft- their commercial patients enrolled in the ware developer.) ME-Cares program. Post-Grant Activity Looking Ahead All three hospitals have funded positions to The MHA’s challenges going forward are based continue care management services to target- on industry conditions outside of their immedi- ed patient populations. Reimbursement for ate purview. The most important questions to these services will be provided through the be answered for the MHA will be: state ME-Cares program for Medicare patients. In addition, one of the largest insur- x Will care management responsibilities and ance providers in the state, Cigna Healthcare expenses reside at the payer/carrier level, of Maine, has committed to buying care man- or will they be delegated to community- agement services from all 11 MHA hospitals, level providers? which includes the three grant participants. x Is community-based delivery more costly for the payer/carrier? A fundamental issue with care management is ongoing funding for these services. Few if x Is community-based delivery of care man- any payers at this time directly reimburse for agement more effective for the payer/carrier? care management services. CIGNA is one exception. Medicare has a five-year demon- 21 Southwest Texas Network: Conquering Compliance in a HIPAA-Dominated World Southwest Texas Network History and Background of Network pliance, and utilization data. A major barrier to members success was the lack of internal resources to The Southwest Texas Network (STN) was implement comprehensive corporate compli- Atascosa Community Health Center established in 1998 as a practice manage- ance programs in adherence to guidelines pub- Pleasanton, Texas ment network based in San Antonio. The lished by the Office of the Inspector General Barrio Comprehensive Family Health network consists of five non-profit, federally (OIG). Care Center, San Antonio, Texas qualified health centers (four rural, one urban) in southwest Texas. Its service area Community Health Development STN sought a targeted consultation from the includes 10 medically underserved counties Uvalde, Texas Networking for Rural Health project to lay the in South Central and Southwest Texas. Faced foundation for a comprehensive corporate com- with growing numbers of uninsured and pliance program. Corporate compliance refers Service Area (counties) underinsured, changes in Medicaid reim- to the need for health care providers to comply bursement, and shifting needs for specialty Atascosa with federal and state regulations regarding the services, early network members solidified Real control of waste, fraud, and abuse of reim- Uvalde their organization and formed the STN. bursement dollars mostly within the Medicare Val Verde and Medicaid systems. Zavala Early collaboration between some of the net- Maverick work members began in the late 1980s and Bexar A compliance plan is preventive. It identifies early 1990s. Funding came from the Bureau of Dimmit what kinds of activities are illegal under federal Primary Health Care’s Integrated Services Edwards and state law and determines how they can be Development Initiative and partnership contri- Kinney avoided in order to prevent prosecution. butions. The STN aims to help the five centers develop individual infrastructures that support the services necessary to serve the uninsured The following are the high-risk areas that are and underinsured people in the network’s serv- most often included in compliance programs, ice area. and the problems they aim to prevent: Originally, the STN set the following goals: x Coding and billing: using the wrong coding or modifiers; x To improve coordination of services; x Reasonable and necessary services: failing x To promote trust and effective to obtain approval for services before communication; providing them; x To set priorities for their limited x Documentation: failing to record relevant resources; and information on a patient’s medical record; x To share information to enable x Referrals: kickbacks; compliance and continued performance improvement at each center. x Record retention: inappropriate length of time to retain records; During its first year, the Texas Health and Human Services Commission awarded a x Certification: inappropriate certification, Children’s Health Insurance Plan Community typically of medical suppliers or home Based Outreach (CBO) Services Contract to the health services; and STN. In addition, the STN engaged consultant x Professional courtesy: no collection of services to analyze fiscal management, improve co-pays. reporting mechanisms, and begin to develop software systems to capture productivity, com- 22 With the help of consultants, the STN devel- x National Association of Community oped the following compliance-related materi- Health Centers (training and compliance als and activities: guidelines); x Healthcare Management Advisors x Two coding training sessions and a (compliance hotline); and documentation training session; x Ronda Hajduk, MBA, RHIT (network x Training on data analysis from a financial compliance officer). specialist; The network believes that it positively influ- x Video orientation tape; enced the compliance program process for the x Compliance manual; centers. It used a hybrid form of Ernst and Young’s Leading Practices Survey to identify x Toll-free compliance hotline; and benchmark best practices for compliance, x Contract with a network compliance and establish a baseline for future tracking. officer; and This form is used throughout this case study. x Legal counsel for policy reviews. Overall, 100 percent of the centers agreed that The following consultants were engaged as part the network was effective at establishing com- of this effort: pliance standards and procedures that are believed to reduce misconduct. (See Table 7.) x Cox & Smith, Inc. (seminar on medical All of the centers have developed a code of con- documentation to improve patient care duct that communicates the centers’ objectives and avoid liability, compliance video); and fosters a corporate culture that not only detects, but also prevents, misconduct. x Bonnie Lewis-Brown & Associates (coding workshops); Essential Elements of the Corporate Compliance Program Table 7: Establishing Compliance Standards and Procedures Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not A code of conduct that is designed to prevent and detect misconduct 100% 100% Multilingual versions of the code of conduct 100% 75% 25% Standards and procedures that are easy to comprehend 100% 100% A code of conduct that promotes a “compliance culture” within the organization 100% 100% A code of conduct that provides appropriate references and contacts regarding the organization’s compliance-related policies, procedures, and reporting systems 100% 100% 23 Table 8: Creating a Compliance Infrastructure Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not Upper management demonstrates commitment to ethical conduct (the tone for ethical conduct is set “at the top”). 100% 100% The organization has a compliance officer or team leader. 100% 100% Compliance oversight is assigned to the compliance committee or equivalent. 100% 100% There is high-level oversight of compliance, legal, and regulatory matters; there is a network compliance officer. 100% 100% The compliance officer is “dedicated” (i.e., does not have additional duties other than the oversight of the compliance program). 100% 100% The compliance officer has direct access to the CEO and/or the board. 100% 100% The compliance committee addresses compliance matters on a regular basis. 100% 100% The organization’s budget for compliance-related matters adequately reflects its commitment to good corporate conduct. 50% 50% 100% The centers understand the importance of issu- sions have widened employees’ access to com- ing standards that are easy to comprehend. pliance information and understanding. However, the necessity for multi-lingual ver- sions of the code of conduct was felt to be only Networking for Rural Health funding made slightly to moderately essential. The guidance is it possible for the network to secure full written at a level that can be understood by legal review of the code of conduct and poli- employees of varying education levels, reading, cy templates by an independent law firm and comprehension skills. In addition to writ- specializing in health care law and health ten policies, codes, and standards, training ses- system compliance. 24 Overall, the network has been very effective The centers have been moderately to very at creating a compliance infrastructure for effective in conducting due diligence. each of the centers. (See Table 8.) While there is (See Table 9.) While effective internal control upper management buy-in and support, the structures were in place prior to the compli- centers each have a compliance representative. ance programs, the centers now have There are assigned compliance teams and high- heightened awareness through internal sys- level oversight of compliance matters. Only tem strengths that extend beyond compli- moderate financial appropriations have been set ance and positively affect financial and clini- aside at the center level for the compliance pro- cal performance. Although no studies have gram. For this reason, each center’s compliance been conducted to quantify the impact, the officer has additional duties within his or her compliance concentration has enabled the organization, and none of the current year centers to encourage productivity and effi- budgets for the centers appropriate direct fund- ciency by linking the internal control struc- ing for compliance-related expenses. The net- ture with performance measurements that work consolidates certain costs that enable the are in part based on compliance objectives. centers’ part-time compliance officers to do An important activity was a “secret shopper” an excellent job. program, in which consultants present themselves as patients to network providers. Expenses are viewed as the responsibility The purpose was to give the centers a of the network and are governed by the net- view of their service delivery from a cus- work’s ability to attract and maintain addi- tomer’s perspective. tional grant funding for the continuation of the compliance project. Table 9: Conducting Due Diligence Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not The centers screen new hires, agents, and business partners. 100% 100% “Know your customer” policies and procedures 100% 100% A system to verify potential employee credentials and review their backgrounds 100% 100% Documents adequately consider related risks and incorporate appropriate safeguards regarding commercial relationships with vendors and agents. 100% 100% 25 Table 10: Communicating Standards and Procedures Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not Required compliance training for all subcontractors, agents 100% 100% A center “hotline” or reporting system where employees can report misconduct without fear of retribution 100% 100% Consequences of failure to comply with the code of conduct and center standards and procedures is communicated to all employees. 100% 100% High visibility of references and contacts regarding how to obtain compliance information and report misconduct 100% 100% All employees, including new hires, are required to have compliance-related training. 100% 100% Contractors are informed about the center’s commitment to ethical and lawful conduct and directed to behave consistently with the company’s relevant policies and procedures. 100% 100% When appropriate, training programs are offered. 100% 100% 26 Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not Information received from the “hotline” or internal reporting systems accurately reflects potential problems within the center. 100% 100% Employees are encouraged to report misconduct without fear of retribution. 100% 100% Training materials and information pertaining to compliance-related standards and procedures are easily accessible. 100% 100% The centers have been very effective at com- information systems have played a critical municating standards and procedures to role in the network’s decision to purchase an all employees and other agents through integrated practice management system. training programs and other mechanisms. (See Table 11.) While funding for the purchase (See Table 10.) The network was able to suc- was not directly associated with the project, the ceed at this effort in large part because of network and centers’ willingness to voluntarily project funding, which made it possible to police their internal processes and to gather, produce a training video for new employee store, and maintain information using orientation and staff re-orientation, and to advanced technology came largely from compli- purchase a toll-free hotline service to serve ance and financial educational opportunities as an objective and anonymous access point facilitated by the project. for employee reporting. Project funds also allowed the network to develop a policy In preparation for extended responsibilities for resource manual and compliance-related billing and HIPAA compliance, the STN is tak- training materials, and to outsource sanc- ing the next step toward securing a fully inte- tion check services for each of the centers grated practice management system. As they through a reputable provider. A sanction implement this system, the centers will take a check is a screening of individuals and busi- detailed look at auditing and monitoring sys- nesses barred from participation in govern- tems that are in place and extend systems that ment-funded programs against government do not encompass compliance areas efficiently. databases. In addition to auditing and monitoring stan- Heightened awareness of compliance issues, dards, the network and its participating centers the ramifications of fraud and abuse, and the are working to standardize internal controls for availability of more sophisticated management enforcing compliance standards. 27 Table 11: Establishing and Maintaining Internal Controls, Books, and Records Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not A policy that requires the center to maintain an effective system of internal controls as well as books and records that accurately reflect its transactions and disposition of assets 100% 100% The policy clearly and concisely prohibits “off the books” accounts, inadequately identified transactions, and false entries. 100% 100% The center has established accountability for enforcing these prohibitions throughout the organization (e.g., departments, sites/locations). 100% 100% Independent outside auditors oversee the structure of internal controls, the financial reporting process, and related 100% 100% functions. At this point, the number of employee and culture, education, and staff awareness. While patient reports to the centers is insignificant. it is difficult to measure the effectiveness of the Two reports have occurred over the course of response of the centers and their ability to take the project; both were clearly not compliance steps to prevent further offenses, it is reassur- issues and subsequently were handled outside ing that the need to use these measures has not of the parameters of the compliance program. been necessary. (See Tables 13 and 14.) The independent hotline service provider logged all calls and, while the content was not Despite the small number of reports, the pres- disclosed to the STN (as contractor for the cen- ence of the compliance program fosters the ters), there is a full listing of all calls. Lack of compliance culture of each center and creates quantifiable data demonstrates that there is an an awareness of the boundaries of acceptable insignificant volume of violations, due largely behaviors within the organization. to the network’s efforts to develop corporate 28 Ancillary Outcomes of Compliance Problems within the centers are perceived as Program Implementation being resolved more quickly and trust is enhanced because the mechanisms, proce- The main purpose of a corporate compli- dures, and culture for exposing fraud and ance program is to ensure compliance with abuse are structured and straightforward. all federal and state law and regulations, but Everyone inside and outside of each center there are other benefits of equal impor- knows the type of behavior that is acceptable to tance. An effective compliance program that organization and the ramifications of vio- demonstrates to employees, clients, and the lating these standards. community that the center has a strong commitment to fair and responsible corpo- While the centers are well aware of the legal rate conduct, that it values the quality of advantages of having a compliance program, patient care and customer satisfaction, and they do not yet know how such a program will that it understands the importance of reduc- affect the internal staff and operations or ing waste. patient satisfaction. This will be the topic of extended studies within the organization. Table 12: Implementing Auditing and Monitoring Systems Develop auditing and monitoring systems to include: Next Steps Procedures for regularly auditing compliance to Next steps for the compliance program include development of determine whether each element of the program is internal and external auditing devices to ensure implementation of the functioning as appropriate objective measurements necessary for performance evaluations and management feedback on the program’s success and barriers to success. Audits, internal audits, or compliance functions that perform the following: The network recognizes that, without some form of auditing, the compliance function cannot provide measurement and feedback and Interview employees and third-party will not allow the centers to identify and maintain controls effectively representatives; in high-risk areas. Examine “due diligence” files, agreements, and other documents associated with third- party relationships; and Examine accounts pertaining to revenue received from patient accounts. A mechanism to report and correct any weaknesses or deficiencies noted in the audits in a timely manner Auditing and monitoring systems designed to detect misconduct within outside vendors, affiliates, and agents Risk-related auditing and monitoring systems reviewed by an outside entity 29 Table 13: Enforcing Compliance Standards Develop auditing and monitoring systems to assure: Next Steps Compliance matters are considered in performance While each center has internal controls, there are no formal evaluations. mechanisms in place to measure how effective the centers have been at enforcing compliance standards consistently through disciplinary Sanctions are proportionate to the violation and serve mechanisms. These steps are taken from the Ernst and Young model as a deterrent. and will be replicated to enforce compliance standards across the STN. Disciplinary action for compliance infractions is consistently enforced at all levels of the organization. There is an established protocol for handling misconduct once it is reported or detected. Commercial relationships with outside entities, including customers, are terminated once unethical or unlawful conduct is detected. As STN integrates new techniques and busi- Preparation of a compliance plan can be ness office efficiencies, it stands to reduce debt viewed as a preparation for HIPAA compli- and reimbursement barriers. Through eligibili- ance. Because HIPAA focuses on privacy, accu- ty and referral upgrades as well as privacy and racy, and confidentiality of patients’ medical security measures, patient relations should records, any knowledge gained about how serv- improve. The collaborative relationship with ices are translated into coding would enhance key partners should enhance the overall prod- the accuracy of patient information. uct of health care services and delivery for patients. STN should achieve reasonable com- Definitive implementation and compliance pliance with federal and state regulations, and deadlines will be met to ensure that all of the it should carry through many of the goals of network’s centers are functioning within state the compliance program. and federal laws. Compliance with HIPAA will improve the efficiency and effectiveness of the Plans for HIPAA Compliance delivery system by standardizing the electronic exchange of administrative and financial data. Unlike the STN’s compliance program, HIPAA In addition, the centers will take all measures compliance is not voluntary—it is the law. to protect the security and privacy of individual- HIPAA involves: ly identifiable health information. 1. Standardizing electronic patient health, STN anticipates that preparation for HIPAA administrative, and financial data; compliance will allow centers to achieve effi- ciencies in the following areas: 2. Unique health identifiers for individuals, employers, health plans, and health care x Claim submission/coordination of benefits; providers; x Remittance; 3. Security standards protecting the x Patient eligibility; confidentiality and integrity of past, present, or future “individually identifiable x Referrals and authorizations; and health information.” x Claims status. 30 Table 14: Responding to Violations and Taking Steps to Prevent Future Offenses Does the Center’s Compliance Program Include How Important Is this Element to a Corporate this Element? Compliance Program? Program Element Yes No Extremely Moderately Slightly Not Program is revised to reflect changes in laws, regulations, and policies. 100% 100% When misconduct is detected, standards and procedures are reviewed and revised as needed to prevent similar behavior in the future. 100% 100% The center periodically reviews compliance and risk-related standards and procedures to analyze efficacy. 100% 100% There is an ongoing effort to keep the compliance program a vital part of the , 100% 100% center s culture and infrastructure. Prior to HIPAA, claim submission required STN will be able to use the following standard- hundreds of payer-specific data elements ized code sets: in multiple formats. Over 60 percent of patient claims were sent on paper, and it x ICD-9-CM (diagnosis and procedures); took many days to pay “clean” claims. Post-HIPAA, there will be standard code x CPT-4 (services of physicians, other sets and one standard claim format. professionals); Moreover, 95 percent of claims will be han- x HCPCS (products, supplies, and dled electronically, and “clean” claims are services); and anticipated to be paid within 30 days. x CDT (dental services). Claims payment will be simplified under There will be no local codes, and National Drug HIPAA to allow for automatic posting of Codes will be retracted. National Drug Codes, payments. Previously, centers were required developed by the U.S. Food and Drug to determine insurance eligibility only by Administration, are used in reporting prescrip- inquiry and to copy the insurance card, send tion drugs in pharmacy transactions. Everyone the claim, and wait for the payment. If the will be on the current code version. claim was rejected, centers had to verify insurance, resend the claim, and wait again HIPAA compliance will be implemented for the payment. Post-HIPAA eligibility will through the following steps: eliminate the claims rejection, verification, resending, and waiting functions. x Education (HIPAA orientation tape, videoconferences, meetings, and the posting of HIPAA articles on the STN Web site); 31 x Executive support (awareness presentations x To lodge complaints regarding PHI. to governing board members); Many additional issues are anticipated in this x Identification and inventory (surveys and implementation process as the centers consider exercises to identify and inventory patient everything from fax machine locations to the information flow, storage, and access); types of shredders they should use to answer- ing machines, to sign-in sheets. x Vendor contacts (establishment of business agreements to ensure electronic data The HIPAA implementation process will allow exchange efficiencies); the centers to detail current health information x Gap analysis (map the HIPAA security policies and procedures and list the organiza- requirements against the center tions that receive health information from environment to identify gaps in the security them. STN will collect examples of current con- infrastructure); sent forms, notices of privacy practices, and authorizations, and ensure that all contracts x Contacting health plans (contact health plans with “business associates” meet compliance that process electronic claims for assurance review standards. They will spend additional of HIPAA compliance); and research time on state laws to ensure that the x Testing of systems (a series of internal and standards they impose not only comply with external surveys and audits to ensure federal regulations but meet their own stan- compliance with HIPAA standards). dards as well. STN will work with the centers to designate a health information privacy official In addition to modifications of transaction who will be responsible for developing and codes and datasets, the STN was required to be implementing privacy policies and procedures. in full compliance with privacy standards by April 14, 2003, and has until April 14, 2004, to In summary, the HIPAA security elements that modify existing business associate contracts. have been developed include: The STN must designate a privacy officer at each of the centers, provide privacy training to their workforce, implement safeguards to pro- x Technical security mechanisms to guard data tect health information from intentional or integrity, confidentiality, and availability; accidental misuse, and provide individuals with x Technical security service process that must a means to lodge complaints about the center’s be put into place to protect, control, and information practices. monitor information access; STN must also develop a system of sanctions x Physical safeguards in the form of policies for staff and business partners who violate their and procedures for ensuring authorized policies and further establish contracts with physical access; and business associates that ensure that they will x Administrative policies, procedures, and exercise an appropriate level of care related to organizational practices dealing with the Protected Health Information (PHI). All of behavioral side of security. their policies and practices must be document- ed and followed. Net gains from the privacy elements of the HIPAA program include: There are new patient rights that will be addressed: x Standard set of policies and procedures; x Standard set of patient expectations; x To inspect, copy, and amend the medical x Protection from federal fines or prison time; record; x To appeal amendment decisions; x Protection from state-level action; and x To be given copies of notice of privacy x Compliance with accreditation bodies; policies and procedures; x To be given signed authorizations for the release of PHI; and 32 Lessons Learned Variation in the level of skill among designat- ed compliance officers was an issue. A billing The CEO of STN points out that success starts officer with only a high school education was at the top. Compliance was not a top priority at a compliance officer at one center, while a all facilities. Getting good participation in con- person with more education and knowledge ference calls with compliance officers became a about coding and billing took on that role at problem. She suggests doing a comprehensive another. Yet another center designated their review with all stakeholders to communicate COO. Some compliance officers who were what is necessary to implement a program and asked to report to their board had never what the desired outcomes are. Getting the attended a board meeting before. None of the board “on board” was key. She needed the centers had had a seasoned compliance per- endorsement of the board to bolster the author- son at the start of the grant period. ity of the network compliance officers. If the board didn’t understand its responsibility, then they were re-educated. This required CEO-to- Post-Grant Activity CEO communication in some instances. The Since the time when the network was awarded administrative staff also needed to understand its grant from the Networking for Rural Health what compliance meant and what their role in project, its funding has increased significant- achieving it was. The video was invaluable ly—from $280,000 to more than $1 million because it could be used at all facilities and annually. Project funding helped to strengthen updates could be added to it. and integrate the systems needed to obtain additional funding. Table 15: Network Funding Integrated Service Development Initiative (ISDI) Grant – To facilitate the $65,000 integration of delivery systems as well as for planning activities. TexCare (CHIP) Grant – To provide application assistance and educational $101,000 outreach to parents of qualified children in nine South Central and Southwest Texas counties. Community Access Program Grant – To provide the infrastructure $627,000 necessary to fully develop or strengthen integrated health care systems that coordinate health services for the uninsured. Shared Integrated Management Information System (SIMIS) – To $350,000 strategically align health center information systems with business objectives in an effort to meet demands driven by competition in the marketplace. Partner/Membership Contributions – Annual membership fees that help to $21,000 support network operations and staff salaries. Total: $1,164,000 33 Summary x Incurred only a small number of reports of violations; and Funding through the Networking for Rural Health project has played a significant role in x Completed detailed plans to address and enabling the STN to mount a significant, comply with HIPAA standards. impressive, and ongoing compliance program. However, several areas need additional work. The executive director of the STN reports that For example: the network is well ahead of the rest of Texas in their compliance implementation and have: x The internal staff and operational benefits as well as patient satisfaction outcomes of x Established compliance standards and compliance efforts remain somewhat procedures that are effective in reducing unknown. misconduct; x None of the centers have dedicated x Held training sessions to increase employee compliance officers; all compliance officers access to compliance information and have additional duties. Pooling of resources understanding; is an important contribution of the network. x Been able to fund full legal review of the However, as each center’s needs grow, full- code of conduct and policy templates by an time compliance officers may be necessary. independent law firm specializing in health x Center participation in ongoing audio- care law and health system compliance; conferences continues to be a problem. x Implemented a “secret shopper” program to The centers are short staffed and on tight get an objective outside view of service budgets. Time spent attending audio- delivery; conferences takes away from patient service time. x Been effective at communicating standards and procedures to all employees and other x Continued compliance efforts are dependent agents through a policy resource manual, a on new grant funding. training program with materials, a toll-free hotline for anonymous staff reporting, and Replicability an orientation video; Both the manual and the video could be adapt- x Purchased an integrated practice ed for use by other networks, although neither management system; has been developed for use outside the STN so x Made plans to take a detailed look at auditing far. The STN would need to obtain the consent and monitoring systems that are in place and of its attorney, who is the presenter of the com- extend systems that do not efficiently pliance workshop, before distributing the video- encompass compliance areas; tape. x Made plans using an Ernst & Young model for enforcing compliance standards; 34 Upper Peninsula Health Care Network: Using Local Resources to Overcome Personnel Shortages History and Background of Network In 2000, the UPHCN’s budgeted revenues Upper Peninsula Health Care were $353,000. The 2003 budget submitted Network members The remoteness, sparse population, and and approved at the UPHCN board of trustees Baraga County Memorial Hospital severe winter weather of the Upper meeting in December 2002 projects revenues L’Anse, Mich. Peninsula (UP) of Michigan make access to of $1.6 million for the year. The most signifi- Bell Memorial Hospital medical services a serious problem. Many cant component for this large increase was the Ishpeming, Mich. rural communities throughout the UP lack addition of a mobile MRI that provides service primary health care or easy access to health Dickinson County Healthcare System to five hospitals in the UP. Iron Mountain, Mich. services, and thus fall under the federal and state guidelines of Health Professional Grand View Health System The network wrestled with assessing which Shortage Areas (HPSA) and Medically Ironwood, Mich. services should be selected to increase access Underserved Areas (MUA). Retention and Great Lakes Behavioral Health, Munising to care and improve quality of care. They recruitment of physicians and other health Escanaba, Newberry, Marquette, Mich. wanted to identify the program that could professionals is a constant challenge because Helen Newberry Joy Hospital benefit the largest number of communities of professional isolation, distance from spe- Newberry, Mich. with the most efficient use of resources. To cialists, and limited continuing education. Iron County Community Hospitals deal with these issues, the network board decided to develop a needs assessment and a Iron River, Mich. The UP is located in one of the northernmost business plan, and then to design and imple- Keweenaw Memorial Medical Center sections of the Midwestern United States. Laurium, Mich. ment an appropriate program. Lakes Superior, Michigan, and Huron are natu- Mackinac Straits Hospital ral boundaries, limiting access to the Upper St. Ignace, Mich. UP. According to 2000 Census data, the UP is Targeted Consultation home to 318,000 residents. It spans 16,600 Marquette General Health System The network sought a targeted consultation Marquette, Mich. square miles, with an average of 19 people per to help develop the needs assessment square mile. and follow-up planning. It was awarded Munising Memorial Hospital Munising, Mich. $40,000 from the Networking for Rural The Upper Peninsula Health Care Network Health project. The original goal of the Ontonagon Memorial Hospital (UPHCN) in Marquette, Mich., was formally targeted consultation was to: Ontonagon, Mich. incorporated as a non-profit in June 1995, with Portage Health System 501(c)(3) status received in April 1996. With an x Conduct an assessment of the community Hancock, Mich. original membership of 14, the network now needs; Schoolcraft Memorial Hospital has 16 members: a regional medical center, 13 Manistique, Mich. community hospitals, a tribal health center, and x Determine the market; Sault Ste. Marie Tribal Health Center a behavioral health provider network. All 16 x Determine available resources; and Sault Ste. Marie, Mich. members of the network are private or public War Memorial Hospital non-profit organizations. x Develop a business plan. Sault Ste. Marie, Mich. The network engaged the Northland Health The original focus of the UPHCN was to serve Group (South Portland, Maine) for this targeted Service Area (counties) the residents of the Upper Peninsula of consultation. Baraga Michigan through: Marquette Dickinson The first step was to survey the board of Gogebic x Promotion of managed care networks; trustees and conduct a board retreat to review Luce the results and discuss options and opportuni- Iron x Cooperative hospital services; ties. After the Northland Health Group con- Keweenaw x Availability of education; ducted an initial needs assessment, the board Mackinac of the UPHCN instructed the network director Alger x Access to health care; Ontonagon to focus only on personnel shortages—an issue x Assurance of professional standards; and of paramount importance to the membership Houghton and the board. Part of the reason for this was Chippewa x Dissemination of information on current Schoolcraft staffing. The executive director and an adminis- legislative and economic issues. 35 trative assistant had little time for long-term Community College in Ironwood, Mich., indi- strategic planning, because they were busy cating that his school had developed a coding managing eight network committees and program but had no students. organizing a new group purchasing program. After the decision was made to forgo a larger At the same time, an organization called planning effort, the relationship between the Michigan Works: The Job Force (formerly, Northland Group and the UPHCN was amica- the Michigan Employment Security bly terminated. Commission) also contacted the network’s executive director to express interest in Focus on Personnel Shortages working with the UPHCN to improve awareness of jobs available in health care The UPHCN decided to focus on the crucial and specifically in coding positions. shortage of coding personnel because the short- age was having a major impact on hospitals, These discussions led to two main initia- and the network had a good chance of succeed- tives, one short-term and the other long- ing in addressing this issue. term, that were pursued through the com- bined efforts of Michigan Works, Gogebic The shortage of coding personnel is part of a College, and the UPHCN. global problem of attracting health profession- als to a rural area. Although it is often very The short-term initiative was to seek continu- expensive, agencies can provide nurses and ing education for coders currently on staff at radiology technicians. However, the availability member hospitals. The longer-term initiative of coders is very limited. was to design a curriculum for a coding certifi- cate program to train new coders. The UPHCN Qualified coding personnel are in great negotiated the cost for two workshops available demand in the UP and nationwide. Coders are to coders and management staff within the net- critical to hospitals and physicians’ offices. work, which were conducted by Gogebic faculty Sufficient coding staff permit a faster turn- and staff. Basic coder education was a one-day around of patient bills and consequently seminar available to department managers to improve cash balances by reducing days in bring basic coding knowledge to the hospital accounts receivable to these organizations. By departments. The other workshop was conduct- increasing the institutions’ cash flow, each ed over lunch once a week for six weeks. It was member will have a varying degree of return on designed specifically for coders, and provided investment depending on whether they choose continuing education credits for maintaining to purchase investments, buy equipment, or certification. reduce debt. Rural hospitals generally have dif- ficulty recruiting staff and the industry-wide Both of these workshops took place outside shortage of coders makes the situation even of the network and were transmitted worse. Knowing this, the board of trustees over the UPHCN’s video conferencing sys- decided to take a “grow your own” approach. tem. Individuals attending these workshops were given the option of attending via video- Initial Collaborative Attempts conference or live attendance at the instruc- Unsuccessful initial attempts were made with a tor’s location. The American Health local university to expand its staff and resources Information Management Association to develop and implement a suitable training (AHIMA) approved both of these courses program. The UPHCN then began studying for credit. other alternatives to increase the number of qualified coders in the UP. After initially plan- For the long-term initiative, the network decid- ning to develop a classroom-based curriculum, ed to develop a one-year certificate program they discovered that there were very credible rather than a two-year associate program training programs for these positions that because of the pressing need. At the time of the could be taken over the Internet. Word had initiation of this effort, there were 16 coder spread that the network was trying to address vacancies in the network hospitals. The first the issue of coders, and the executive director students started the program in fall 2001. received a letter from the dean of Gogebic Medical records staff felt it was important for 36 the Gogebic program to be accredited to help Implementation Issues with the recruiting process locally but also to One issue that was a real dilemma was how to allow Gogebic to market the program regional- set up the sequence of classes with students ly. Accreditation through AHIMA or another entering the program who had different levels organization is under consideration. of educational experience. Some advanced nurses didn’t need training in anatomy and Students will be able to sit for certification physiology, for example. Without sufficient exams after six months work experience. numbers of students for a particular course, it Position profiles are being developed by was not cost-effective to hire an instructor. How Michigan Works to determine the minimum do you set up a continuum of classes in order requirements for students entering the pro- to keep a full contingent of students? The exec- gram to ensure that it attracts high quality utive director reports that Gogebic started the enrollees and has a high completion rate. A entire first half of the curriculum in the first unique feature of the Gogebic program is that semester after consulting with medical records it uses local mentors. Local hospital employees staff in network hospitals. mentor students who train online. Students are recruited out of high schools and Application to Other Personnel other health professions such as nursing. A Shortages coding career may be attractive to nurses who The “grow your own” approach of addressing are under significant work pressure because of industry personnel shortages has drawn inter- nursing shortages. est from network hospital administrators. The UPHCN Radiology Committee is now explor- Programs exist within network hospitals for ing a modified strategy to address the shortage tuition forgiveness. In other words, hospitals of radiology technicians. will pay tuition if students work at the hospital for two years following their training. If the stu- The shortage of radiology technicians is a dent doesn’t work for the entire period of the major national problem. Marquette General contract, he or she must pay tuition on a pro- Hospital’s (MGH) radiology school accepts six rated basis. In addition, a new scholarship pro- applicants per year. Radiology departments are gram has been discussed, but not finalized. financially advantageous for hospitals. The UPHCN has started working with MGH to Post-Grant Developments expand its program from six to ten positions per year. The plan is to provide incentives or The coding program has advanced beyond the have the network take some equity out and network’s original expectations. It allows 20 invest in expanding the program. students to enter each year in the fall. Twenty students entered in fall 2001, another 20 in fall 2002, and six students are already scheduled to Another issue was whether the school should begin in fall 2003. The program is expected to take on another radiology instructor and addi- take two years to complete but can be finished tional training sites around the UP. At about sooner if some pre-requisites are waived for the time when the network was conducting a experienced students and if circumstances financial analysis, a large radiology practice regarding class sequence allow. with offices at MGH disbanded. Students are required to perform a number of procedures every year to pass certain competencies. It was As the program is new, there have not been any felt that some of the hospitals didn’t have suf- graduates as of this writing. There have been ficient volume to warrant a site for students to no dropouts either. According to Gogebic staff, meet their competency requirements. four hospitals in eastern Wisconsin and five hospitals in the UP have committed to a men- torship program. In this program, practicing After the radiology group disbanded, Marquette coders pair up with students online, help stu- General took over their site at the medical cen- dents with classwork as needed, and share real- ter, thus providing a large volume of procedures life experiences from their coding positions. for students. They were able to achieve this without hiring an additional instructor, leading to savings of $50,000 to $80,000 a year. 37 Lessons Learned Summary The most important lesson learned from the The network is well on its way to relieving the consultation was that the network needed to shortage through its ongoing education of quali- perform more formal planning. In the past, ty coders. However, the health care industry the executive director would have ideas fun- overall is experiencing extensive shortages of nel in from board members intermittently. qualified personnel in many different areas, The ideas often were not developed further especially radiology technicians and nurses. The after presentation to the full board. It was overall approach resulting from this grant was difficult to gain consensus because of the to “home grow” coders with incentives and uti- wide diversity of network members’ needs. lization of local resources. There is already dia- Members of the network placed their institu- log among the board of trustees and various net- tional needs ahead of network decisions. work committees to explore the same approach Being able to gain buy-in from members for radiology technicians. required an expensive business planning process for each proposed project that The network has shown that it can build pro- included documenting the costs and benefits grams within the UP and make them attractive to the member institution as well as to the to its local community by addressing the prob- network as a whole. To some extent, board lems that network members share. UPHCN members realized this problem; however, the has started to look at the next area to target. Northland Health Group helped the UPHCN Using the model developed for personnel short- identify that a more formal planning process ages, it will explore developing a network collec- was necessary if new programs were to be tion agency. Plans are being made to recruit initiated. people from local agencies or banks. Indirect Effects Further Information The original intent of the grant was to identify Recent Grant History opportunities and develop business plans for x In July 2000, the network undertook a rural implementation. The first initiative evolved health initiative funded by the Michigan around a particular issue—personnel short- Department of Community Health, titled ages—and coders in particular. An added bene- “Minimizing the Distances: Expanding fit of the Northland Health Group’s consultation Telecommunications Connectivity for the was the board’s realization that the network was Upper Peninsula Health Care Network.” undertaking too many activities with too few This $200,000 grant was primarily an staff. To address this, the board funded a new equipment grant that funded the purchase operations position in the executive director’s of an expanded, enhanced videoconference office in August 2002 to assist with all commit- system. tees and analyze the costs and benefits of vari- x The network began a rural health initiative in ous network initiatives. 2001 funded by the Michigan Department of Community Health, titled “Building Replicability in Other Networks Collaboration and Efficiencies among Several elements came together at the right Medical Control Authorities.” The network place and the right time to enable this effort to will use the $86,000 grant to create a succeed. The network was fortunate to have medical control authority network in 11 come across a coder training program in need counties of the Upper Peninsula to of students just as it had embarked on a search collectively address the mandates recently for one. However, coder training is available published by the state. Medical control online, and therefore replicable almost any- authorities are the responsibility of hospitals where. Mentorship programs can be developed in Michigan and are the oversight body for through member hospitals. Since rural net- emergency medical services in the counties works have shortages of key medical personnel, for which they reside. the UPHCN model of working with local insti- x Blue Cross Blue Shield of Michigan tutions of higher learning, state employment Community Health Agenda, through their agencies, and network hospitals to create train- preventive health program in August 2001, ing programs in key areas should be replicable funded the full purchase of 10,000 residential in many rural settings. smoke detectors at a cost of $47,000. 38 Appendix: Targeted Consultation Grantees* Network/ Amount Service Grant State Location Awarded Composition Area Objectives Colorado Frontier Health $10,000 12 members, Kit Carson Develop Network including County collaborative 242 South 14th St. hospitals, (7,300 pop.) strategy for Burlington, CO clinics, long- suicide 80807 term care, home prevention. care, and other Review existing social service data, educate agencies members, assess network and community resources, and recommend action plan. Florida Lake Okeechobee $40,000 2 vertically Panhandle To develop a Rural Health integrated and south/ locally owned and Network networks central Fla. operated PPO product on a 185 U.S. Hwy 27 statewide basis. South South Bay, FL 33493 Illinois East Central $10,000 25 members, 7 counties in Assessment and Illinois Rural including county east central Ill. prioritization of Health Network health (144,735 pop. ) prevention 1000 Health Center departments, strategies based Drive hospitals, and on analysis of risk Mattoon, IL 61938 social service behaviors in agencies service area. Indiana Heartland Regional $12,500 4 hospitals 4 counties in Facilitate the Health Network north implementation of 205 W. Sycamore central Ind. a jointly Kokomo, IN 46901 (168,570 sponsored pop.) regional home health care agency. Iowa Crossroads Health $40,000 3 hospitals 3 counties Assist in network Partners in southeast organizational 407 S. White St. Iowa (58,000 development and Mt. Pleasant, IA pop.) refinement and 52641 implementation of business plans. * To read short profiles of all 27 targeted consultation grantees funded through the Networking for Rural Health project, please visit: www.academyhealth.org/ruralhealth/ruralgrantees.htm. 39 Appendix continued: Targeted Consultation Grantees Network/ Amount Service Grant State Location Awarded Composition Area Objectives Iowa Iowa Health $40,000 12 rural 12 counties Create a network (cont.) System hospitals and across rural of interactive Community Iowa Health Iowa Web sites that Network System would reduce 1200 Pleasant St. costs, increase revenue, and Des Moines, IA offer additional 50309 services to consumers. Maine Maine Health $35,000 11 community 5 counties in Develop, Alliance hospitals, 350 northeastern implement, and 18 Stillwater Ave. primary care Maine train staff on Web- Bangor, ME 04401 providers (350,000 pop.) resident disease management software. Mount Desert $22,500 9 organizations: Hancock Design, Island Community health care County, 108 implement, and Health Plan providers, sq. miles evaluate a mental P.O. Box 875 chamber of (10,000 health services Mt. Desert, ME year-round component of the commerce, 04660 pop.) health plan in social services order to be responsive to the community's needs. Massachusetts Dukes County $32,500 32 providers, Martha's Implement phase Health Council social service Vineyard 2 of a 3-phase P.O. Box 1298 agencies, (14,000 pop. project to West Tisbury, MA physicians, in 100 sq. develop a health 02575 miles) plan in order to consumers increase access to services for low-income and uninsured persons. Michigan Upper Peninsula $35,000 16 providers: 1 Upper Conduct an Health Care med center, 13 Peninsula of assessment of Network hospitals, tribal Mich. the community 710 Chippewa (314,000 needs, the health center, Square, Ste. 206 pop. in market, and behavioral available Marquette, MI health 16,600 sq. resources and use 49855 miles) that information to develop a business plan for implementing project(s) that will increase access or improve services. 40 Appendix continued: Targeted Consultation Grantees Network/ Amount Service Grant State Location Awarded Composition Area Objectives Minnesota La qui Parle $15,000 3 hospitals 3 counties Conduct a Health Network (2 in financial analysis 900 2nd Ave. Minnesota, of two potential Madison, MN 52656 1 in SD) ventures: 1) development of a satellite clinic, and 2) shared staffing of emergency room call coverage. Northern $12,200 14 providers: 3 6 counties Develop an Healthcare hospitals, 10 in northern integrated care Partnership clinics, 1 Minn. delivery system c/o Fairview Health regional health of specialty system services: select Services which services to 2450 Riverside integrate, Avenue, 6a West determine how Minneapolis, MN the service lines 55454 should be organized/function, and address related legal issues. North Region $22,000 9 health care Northwestern Develop a Health Alliance systems: 8 Minn.; reimbursement 109 S. Minnesota hospital/medical northeastern model and Warren, MN 56762 clinics, 1 mental N.D. process to be health center used by 8 independent member organizations when negotiating contracts with third party payer organizations. Northwest $40,000 Alliance of small 7 counties Identify and Minnesota Health employers and in northwest develop Care Purchasing individual Minn. specifications for Alliance community (70,250 pop.) new group members insurance option 121 East Seventh Place, Suite 400 St. Paul, MN 55101 PrimeWest Health $40,000 10 counties that 10 counties Assess System provide public in central Minn. operational 305 8th Ave., West health, mental (154,000 pop.) readiness for health, and Medicaid Douglas County managed care chemical Courthouse contracts. dependency Alexandria, MN services. 56308 41 Appendix continued: Targeted Consultation Grantees Network/ Amount Service Grant State Location Awarded Composition Area Objectives Montana Montana Health $29,500 23 hospitals, 3 50 percent Understand the Network nursing homes, of Montana risks, 11 S. 7th Ave. 1 mental health underwriting Suite 160 facility issues, and Miles City, MT project scope associated with 59301 expanding the health plan; develop provider network; and establish a disease management program. New York Health Community $10,000 3 hospitals 4 counties in Develop Alliance western recruitment and 26 Jamestown St. N.Y. retention process P.O. Box 27 (100,000 (especially for Gowanda, NY pop.) surgeons, 14070 psychiatrists, pharmacists, OB/GYN); create a plan to attract LPNs, CNAs, and dental hygienists. Thompson Health $35,000 1 health system, 3 counties in Improve 3170 West St. 1 IPA, 1 payer western information Suite 150 N.Y. systems and Canandaigua, NY (120,000 analytical pop.) capacity by 45133 focusing on specific services, practice patterns, and clinical data to improve managed care readiness. North Carolina Graham Children's $6,000 21 community Yancey and Conduct an in- Health Services of organizations Mitchell depth data Toe River counties collection effort in P.O. Box 1298 order to better address the gaps Burnsville, NC in services or 28714 needs for children and youth in a 2-county area. 42 Appendix continued: Targeted Consultation Grantees Network/ Amount Service Grant State Location Awarded Composition Area Objectives North Dakota Northland $40,000 Hospitals, 32 rural Determine how to Healthcare Alliance physicians, and counties, 2 develop patient 400 E. Broadway nursing homes urban care systems, protocols, and Suite 300 in 13 counties, procedures in Bismarck, ND communities 2/3 of N.D. order to develop 58103 a medical management plan. Ohio Rural Health $20,000 3 hospitals, 1 3 counties Evaluate Cooperative of FQHC in southern managed care Southern Ohio Ohio readiness and 1275 N. High St. develop strategic/ Hillsboro, OH 45133 competitive response options. Oregon Pathways to Care $12,500 1 hospital, 1 Josephine Determine how to 820 N.E. 7th St. physician County integrate Grants Pass, OR practice, 3 (73,000 behavioral health 97526 health depts., 5 pop.) services with primary health social service care services and agencies use appropriate measures of patient outcomes. Pennsylvania Community $25,000 20 FQHCs Rural Pa. Assess Integrated compliance and Services impact of Network of existing clinical Pennsylvania protocols and 1017 Mumma Rd. disease Suite 209-B management Wormleysburg, for high-cost PA 17043 chronic conditions. Texas Uvalde County $16,000 5 FQHCs 10 counties in Develop a Clinic south central comprehensive 201 S. Evans St. and southwest compliance Uvalde, TX 78801 Texas program and educate and train staff in order to comply with standards for practice-based care. 43 Appendix continued: Targeted Consultation Grantees Network/ Amount Service Grant State Location Awarded Composition Area Objectives Vermont Lamoille Valley $20,000 12 community Northern Establish an Long Term Care Team service Vt.; 700 integrated 11 Court St. providers sq. miles management Morrisville, VT information 05661 system to improve and target service delivery by sharing data/information across organizations. Washington Choice Regional $40,000 7 hospitals, 6 5 counties Improve access Health Network health depts., (440,000 pop.) to services P.O. Box 3466 4 clinics, 3 through chronic disease Olympia, WA other entities management 98509 and an uncompensated care pilot program. Wisconsin Rural Wisconsin $30,000 25 hospitals 19 counties Assess Health Cooperative in central feasibility of 880 IndependenceLane and south establishing Sauk City, WI central Wis. virtual 53583 computer network for 25- hospital network. Total Amount $690,700 Awarded 44 1801 K Street, NW Suite 701-L Washington, DC 20006 Phone: 202.292.6700 Fax: 202.292.6800 Web: www.academyhealth.org/ruralheath