Technical Assistance Monograph
ADDING VALUE IN DEVELOPING RURAL INTEGRATED HEALTH SYSTEMS: Approaches to Technical Assistance from the DRIS Initiative
by Luisa Buada, Steven Rosenberg, Gail Nickerson
Funding for this Monograph was provided by:
the James Irvine Foundation of San Francisco, California.
Introduction
Between 1997 and 2001, the James Irvine Foundation undertook a four-year, $6 million Developing Rural Integrated Systems (DRIS) Initiative in four California rural health care markets, with the goal of supporting the development of locally owned health systems entities that could interface with managed care. This paper highlights the value of the different technical assistance approaches that have been utilized in the DRIS Initiative experience. (For more details on the DRIS Initiative.)
Technical Assistance In The Field Of Integrated Health Systems Development
When it comes to the value of technical assistance, communities and health-system developers are still learning from the successes and failures of their efforts around the State and across the country. As facilitators, we try to figure out why certain approaches work with some organizations or communities but not with others. In assisting different communities, our job is to develop the appropriate technical assistance approach for each group of people with which we work. We draw upon our past experiences with varied populations and health systems to enhance the outcomes of technical assistance engagement with each community we encounter.
The challenge of providing technical assistance in the process of community development is a complex undertaking that often entails contributing skill and experience to a project rather than completing a material deliverable. By its very nature, community development means bringing together a diverse array of people to articulate and realize common goals who may be connected only by a shared geographical location and a few interpersonal relationships. This is the job of the technical assistance facilitator.
|
DRIS INITIATIVE IMPLEMENTATION SITES
Key Characteristics of Lompoc Valley
Service area
- Lompoc Valley, Santa Barbara County
- Population ~ 67,000
Market Dynamics at DRIS inception
- Managed care penetration 50% for commercial insurance
- >40% of residents out-migrate for health care services
- Lompoc Valley Health Care Council formed in 1995 (pre-DRIS)
- One managed care contract with local provider network in place
- Provider Network includes local hospital, local private physicians, county primary care clinics, behavioral and social services providers.
DRIS Accomplishments
- Lompoc Valley Community Health Care Organization (LVCHO), community owned 501(c)(3) ASO, formed July 1998
- 50+ member diverse Health Care Council is advisory to LVCHO
- LVCHO is a single signature contracting authority for local provider network
- LVCHO provides contract management, claims administration and medical management support to local provider network
- Obtained a managed care contract with Bureau of Prisons and CIGNA Health Plan
- Awarded> $2 million in Grants since 1999, for substance abuse prevention, community data systems, network
development and access to care for the uninsured. (HRSA CAP grant, California OSHPD, California HealthCare Foundation, County of Santa Barbara)
Key Characteristics of Imperial Valley
Service area
- Imperial County covers 2.7 million rural acres bordering on Mexico
- Population1~44,000, 69% Latino
- >25,000 uninsured low-income children
Market Dynamics at DRIS inception
- Managed care threat from San Diego County
- >38% of residents out-migrate for hospital services
- Shortage of primary care physicians
- Provider collaboration activities in nascent stages, 2 hospitals formed a JPA, physician IPA included 70% of local providers
- Hospital JPA providing contract administration for three commercial health plans
DRIS Accomplishments
- Imperial Valley Community Healthcare Organization (IVCHO) community owned 501(c)(3) ASO, formed July)1999
- 20+ member diverse Health Care Council includes local hospitals, local private physicians, community health center, county health department, local employers, behavioral and social services providers
- Council holds reserve powers to oversee collaborative grant programs of IVCHO and Council organizations
- Awarded > $2 million in Grants since 1999, for behavioral health survey, injury and illness
- Prevention, outreach services to the uninsured, community case management systems, rural network development and access to care for the uninsured. (HRSA Border Health, HRSA Rural Network Development, HRSA CAP grant,
California CMSP, Californian Endowment, California DHS Rural Demonstration Projects)
Key Characteristics of Humboldt-Del Norte
Service area
- Isolated two county service area on the north coast of California bordering on Oregon
- Del Norte County Population ~30,000, Humboldt County Population ~130,000
- Two counties with diverse needs and differing levels of resources
Market Dynamics at DRIS inception
- Managed care threat internal to market area, multiple competing hospital systems
- <9% of residents out-migrate for health care services
- Access available to primary care physicians and community health centers
- History since 1990, of provider and employer collaboration toward the goal of creating a local health plan
- Single Independent Practice Association (IPA) for two county area includes 97% of physicians, mid-level practitioners and mental health providers
- IPA offers TPA and medical management services to local providers
DRIS Accomplishments
- Humboldt-Del Norte Community Health Alliance (CHA), community owned 501(c)(3) ASO, formed April 2000
- 36+ member Advisory Council elects a 9 member business Board of Directors
- The Advisory Council includes hospital, private physicians, community health centers, county health departments, civic leaders, employers, behavioral and social services providers
- Focus of CHA is to increase access to affordable health insurance options for local residents
- Awarded ~$1 million HRSA CAP Grant in 2001 to create an Employee Assistance Program (EAP) for substance users, to create a Del Norte Community Switchboard and to increase enrollment in the Healthy Families (SCHIP) program
|
Providing technical assistance with a community development approach in the field of integrated health systems development is more complex still. For one thing, each party related to the integration process understands the nature of that integration differently. In business, the notion of integrated systems is a fairly new concept, having existed for less than fifty years; in the field of health care, the concept of integrated health systems is still evolving. Pioneered by Kaiser Health and Hospitals, integrated health systems have only recently been accepted by mainstream medicine—since the policy push to use Health Maintenance Organizations as a means to curb health care spending. Urban healthcare environments, which typically have medical provider offices clustered around the hub of a hospital, have more easily entertained the notion of integrating administrative, clinical and financial services to reduce costs and provide a seamless continuum of care by providing a one-stop shop for shared services. However, rural markets—which are typified by low reimbursement payments, an absence of the full spectrum of providers and services necessary for full-service delivery systems, and a paucity of health plan enrollees that are too few to achieve the economies of scale that drive urban integration—require different approaches to technical assistance in order to develop successful integrated health systems.
This analysis of the technical assistance approaches utilized in the DRIS Initiative intends to share the lessons of our experiences with other communities and technical assistance facilitators working around the country to develop integrated rural health systems.
Technical Assistance Benefits Of The DRIS Initiative
The California Institute for Rural Health Management (CIRHM) was the non-profit entity responsible for the inception, implementation and management of the Developing Rural Integrated Systems (DRIS) Initiative of the James Irvine Foundation. The DRIS Initiative was designed to be a technical assistance-supported planning process implemented over multiple years that would result in the creation of integrated health systems in four participating rural areas. The participating rural markets were Humboldt-Del Norte Counties, Imperial County, the Lompoc Valley in Santa Barbara County and the Indian Wells Valley in Kern County.
DRIS was different from most grant programs in several important ways. First, DRIS engaged a broad cross-section of community leaders—including health and social service providers, employers, civic leaders, economic development agencies, and others—in an inclusive dialogue in its community development systems approach. Second, DRIS did not award grant funding directly to participating communities. Instead, sites were provided with extensive technical assistance resources, including expert professionals in managed care systems development, market analysis, community facilitation, data collection, and legal analysis. These professionals, who acted as third-party facilitators in the decision-making process, also produced such technical assistance products as data and feasibility analyses, helped draft business plans and legal contracts, assisted with health plan negotiations, and contributed rural health systems development.¹
When the DRIS Initiative was conceived, its creators at CIRHM, along with CIRHM's advisory committee and the James Irvine Foundation, crafted the technical assistance framework to be responsive to the infrastructure demands of the managed care market as it existed in 1997. The DRIS objectives of developing successful rural managed care models and establishing a single accountable local entity in each of the DRIS sites were perceived by its creators as a necessary response to the universal realities of the health systems business arena. The technical assistance approach took into consideration the fact that most California rural health systems simply would not be able to participate equally as managed care partners in the new world of integrated systems, without considerable resource investment and access to technical expertise. Both CIRHM and the James Irvine Foundation believed that, in order to make a lasting impact, capacity building through facilitation and technical assistance needed to be supported over a sufficient time period (at least three years), and the effort had to include institutionalizing a strong community collaborative that could sustain and support the rural integrated system once it was in place.
This belief was so strong that only rural communities that met the DRIS Initiative founders' selection criteria were asked to apply for this long-term technical assistance project. From the start, CIRHM made clear that inclusion in the project guaranteed technical assistance but not necessarily grant funding. Of course, the notion of technical assistance is somewhat amorphous; its results often manifest more by process than by specific deliverables. In contrast, grant funding provides a tangible and easily understood benefit to recipients, who recognize the obvious monetary value even though the products or services the funds help purchase may ultimately provide little long-term benefit to recipients. Therefore, while the five initial rural communities that signed up for the DRIS Initiative agreed to the process of technical assistance, their inability to assess the exact benefit of the Initiative—financial and otherwise—became a significant hurdle to progress during the first 18 months.² Consequently, the community systems consultants at each of the DRIS sites spent much of their first few months negotiating with community members a mutually acceptable definition of what exactly was to be the "value added" for each community in terms of the technical assistance that CIRHM could offer. This period of negotiation extended the life of the Initiative, which had been conceived as a three-year process, into a four-year process.
There were several technical assistance steps utilized to bring the communities to the point where specific goals could be defined and then achieved. The first was to convene a council of representative leadership from the broader community (beyond the boundaries of health care) to work together with the local health care community to articulate a common vision for the community's health care system. As part of that process, CIRHM engaged data analysts to provide each council with information about the health status of their community as compared with others, a profile of their local health system-including the supply of existing providers and utilization of local services by residents-and information about the cost of health care in their service area. The process of reviewing the community assessment information was used by the community systems consultants to educate participants about their community, to familiarize those not in the health care field about relevant health care delivery issues and c osts, and as a means to help solidify the relationship between the members of the group.
All the aforementioned elements are common to most community planning processes. The DRIS Initiative differed from other technical assistance approaches, however, in articulating specific outcome expectations necessary for each community at every critical juncture in the process. When met, each of these outcome expectations was acknowledged by a milestone grant to the DRIS site community health council. The most critical juncture in the DRIS process was for the community to come to an agreement to choose one or more integrative health system functions related to managed care—clinical, administrative or financial—and to agree either to create or contract with a single accountable entity in their service area to implement these functions.
All five initial DRIS sites reached this stage, four of them by July 1998 and one site by April 2000. Each site either designated or created a 501(c)3 administrative services organization (ASO) and selected a number of clinical, administrative and/or financial functions related to managed care that they wanted to implement with their local provider network. In addition, the four DRIS sites that remained after December 1998 decided to use their health assessment data to apply for grants that could address health promotion and disease prevention issues in their service area. The final technical assistance feat to bring the DRIS sites to implementation, however, required the community systems consultants to bring together the community health council members, the purchasers of the health care services, and the providers of health services to agree on the necessary contracts and prices that would allow the new locally owned entity to deliver affordable and sustainable administrative services to interface with managed care. The difficult task of creating this community owned business required feasibility analyses, contract negotiations and business planning that brought diverse interest groups into concert. Bottom-line decisions required rethinking functions, repeating feasibility analyses, changing financial partners, negotiating compromises, and finding the win-win for each of these groups. Some found the struggle to find start-up capital and create operations systems only to realize a small part of the community's overall mission during the initial years disillusioning. Yet, in the end, three of the four DRIS sites successfully implemented their ASOs by the end of the Initiative, in March 2001.
By the end of the second year, participants and other health system developers working in California began to recognize the "value added" of the DRIS technical assistance approach. Community members found the regular data reports quite valuable, and—along with some help from CIRHM regarding financial analysis, grant writing, and funding—they began to reap the rewards of their collaborative effort. Some of the DRIS sites were awarded grants for health promotion and disease prevention programs that addressed health problems discovered in DRIS community assessment reports. In a Health Affairs, Grant Watch special report highlighting DRIS in 1999, the independent evaluator for DRIS noted that, "when community stakeholders are asked what the most significant impact of DRIS is, they inevitably focus on this process of coming together, strengthening ties, and initiating dialogue."
Today, these new ASOs have been very successful in obtaining grant funding from Federal, State and private foundation sources. Lompoc Valley and Imperial County—which were the first ASOs to be implemented—have each received well over $1 million in grant funding since 1999. Three DRIS ASOs—Imperial County, Lompoc Valley and Humboldt-Del Norte Counties—have each received a Federal Community Access Program (CAP) grant for nearly $1 million apiece to support collaborative health systems approaches to improve access to the uninsured and underinsured in their service areas. That's a 100% grant award rate for DRIS sites competing nationally in the CAP program! While all of the CAP grant writing was supported by funds from the James Irvine Foundation through the DRIS Initiative, two of the three grants were written with minimal or no involvement by the DRIS advisors. As technical assistance facilitators, we view this as a wonderful milestone, knowing that these nascent organizations are successfully finding and achieving results with their own voices.
Targeted Technical Assistance To Rural Networks: Mini-DRIS
The success of this detailed and lengthy technical assistance process, while laudable and valuable to the DRIS communities, cost $6 million over a four-year period. Furthermore, although participants of the DRIS sites may deem their present success worth their own investment in time and energy, it still is not likely that another patron like the James Irvine Foundation will invest in such a lengthy and costly process in the future, particularly because managed care expansion into rural communities has ceased.
In part because of this quandary, CIRHM requested that the approximately $150,000 remaining in DRIS James Irvine Foundation funds be used to help a different set of rural networks with targeted technical assistance strategies while utilizing the lessons learned in the DRIS Initiative. As technical assistance facilitators, we helped these communities set "value added" goals that could be achieved with less funding, more modest missions, and in shorter timeframes. Begun in January 2001, this project was called Mini-DRIS, where the DRIS stands for Developing Rural Integrated Strategies rather than Systems.
In Mini-DRIS, we decided not to trouble with assembling broad representative councils, since there existed neither sufficient resources nor time to support such an extensive process product. Also because of the time limitations, the targeted support had to be a discreet deliverable, executable within a six-month period and easily quantifiable. In this project, we were not concerned about the rural network serving a single rural market. We did, however, want to work with existing formal or informal associations made up of either horizontally or vertically connected providers, which, at a minimum, had selected their leaders. It was important that the leadership of the rural network be able to articulate the network's purpose and the basic goals and objectives of its members. Although we wanted the targeted support to focus on the integrative aspects of rural health networks, such as shared services for the benefit of network members, the Mini-DRIS projects did not require that the assistance be related specifically to managed-care integration.
CIRHM invited several of California's rural health networks to discuss their potential need for technical assistance services. CIRHM offered the following options: to provide facilitative support for community decision-making (short-term strategic planning); to prepare community data assessments or market analysis; to provide community education on specific health care system issues; to perform legal analysis or help with examining health plan contracts (including contract negotiations); to perform feasibility analysis and business planning; to assist with integrated systems planning and development; and to facilitate provider network development. Initially, six networks were interviewed for targeted support. Four networks agreed to accept the technical assistance services and were engaged to participate in Mini-DRIS. Three California rural health networks actually followed through with this engagement and received services from CIRHM and its technical assistance supporters.
Two different forms of support were offered to the three networks participating in Mini-DRIS. The first was general technical assistance related to network organizational development. The second, capacity enhancement, focused on enhancing the networks' ability to fulfill their missions to their member health center organizations in a manner that was supportive of the mission of individual members to serve their patients.
>
Two rural networks received organizational development support to formalize their network structure to be able to receive sustaining and programmatic revenues. CIRHM purchased legal services to help these two networks incorporate and apply for non-profit 501(c)3 status. The two networks are the Coalition of Networks for Northern California and the South County Regional Health Partners.
Coalition of Networks for Northern California (CNNC) is a group of three community health center (CHC) networks along Highway 101 whose purpose is to have a vehicle for projects (grants and otherwise) for which the three networks are best served by working together. Joint projects in the planning stages include information technology and quality assurance. The mission of CNNC directs the Coalition to endeavor or arrange to provide resources to the non-profit CHC members within the Coalition in order to benefit the network patient populations that each serves in their geographical area. The three participating networks are the North Coast Clinics Network, the Redwood Community Health Coalition and the Community Health Services of Mendocino County.
South County Regional Health Partners (SCRHP) is a vertical rural health network that was developed in 1999 to enhance the quality of life in Southern Monterey County through the development of a cohesive, sustainable, coordinated health care delivery system. The goals of the Partners are to provide access to health care and mental health services, provide health education, improve regional case management and referrals. SCRHP evolved organically and informally, bringing key health, education, and social service providers together into the association. As SCRHP began experiencing success at implementing projects and expanding access to clinic services, it became clear that in order to sustain its efforts through grant funding and adequately integrate case management services for medically indigent patients across the different agencies, it would need to be incorporated as a tax-exempt, non-profit organization. The technical assistance CIRHM is providing comes at a key juncture in the development of this rural network.
The second form of technical assistance, capacity enhancement, is being provided to the Central Valley Health Network (CVHN). CVHN is a horizontal community health center network that was created in 1998 when 11 community health organizations in California's Central Valley came together to explore ways to better serve the region's uninsured and medically underserved population collectively. Now with 12 members, the Network's health centers operate in 17 separate California counties with a combined service area of more than 45,000 square miles—nearly one-third of the total area of the State. The centers, with 79 clinics from Chico in the north to Bakersfield in the south, have an aggregate patient population of more than 325,000, and they report more than 1.2 million visits annually. This patient volume makes CVHN the largest single consortium of farm worker health services in the nation. All CVHN members are federally designated health centers—11 as Section 330 Federally Qualified Community Health Centers (FQHCs), and one as a FQHC look-alike.
CVHN was formed by these centers to aggregate resources in order to develop the infrastructure and programs that would enable them to be more cost effective and competitive in the changing health care marketplace. One of CVHN's objectives is the generation of continuing analysis that can enhance and improve member efficiency and cost effectiveness. In this regard, CVHN health center members wished to study the possibility that the network could develop its own purchasing alliance and negotiate more cost-effective health insurance coverage for its employees and their dependents. As an outcome of the analysis performed by one Mini-DRIS consultant—Mike Fadden of Rural Health Consultants, Kansas—CVHN members have decided to explore further a self-funded approach to providing and managing health care benefits for employees and dependents. It is anticipated that member health centers will promote self-funded health care benefit plans and offer incentives for health center employees to utilize the services of CVHN member clinics and lower their overhead costs. This, in turn, will enable the CVHN member health centers to better achieve their mission to serve the medically indigent clients of the health centers.
Conclusion
In the Mini-DRIS technical assistance experience, CIRHM moved from a long-term, health systems developer-directed Initiative process, which was painstakingly negotiated with participating sites, to the delivery of targeted short-term technical assistance strategies, which furthered the administrative integration efforts of network members. While Mini-DRIS in no way compares on scale, scope or complexity to the multiple year DRIS Initiative process or outcomes, a successful feature of Mini-DRIS technical assistance was that both parties (CIRHM and the rural health network) recognized from the start that the proposed assistance would add value. This perception on the part of the participating sites greatly expedited completion of the work and relevant decision making while reducing the overall cost of the support. As in the DRIS Initiative, CIRHM continued to oversee the support process, continued to invite rural health networks for interviews, limited selection of sites to those whose need for technical assistance already was mutually perceived as adding value, and helped choose the appropriate third-party supporters to provide the service.
Thus, as it relates to rural health system integration efforts in California, there are ways that communities with less funds at their discretion than millions of dollars can utilize technical assistance opportunities strategically that add value to rural health networks. While Mini-DRIS cannot provide the complex infrastructure development process of the DRIS Initiative, the focused technical assistance it offers—combined with well-defined products and mutually clear expectations between the client and the supporting agency—certainly can enhance the integration efforts of rural health networks and advance the missions of network member organizations.
The Authors
For more about the authors, click below:
|
