DRIS Logo
DRIS Home
DRIS Initiative
DRIS Newsletters
Tour the 5 Sites
DRIS Functions
DRIS Data
DRIS Contacts
DRIS Evaluations
Indian Wells Valley Home
Indian Wells Valley Summary
Indian Wells Valley Data
Indian Wells Valley Contacts

Section III. Community Process

  1. Description of Community Integration Efforts Prior to DRIS

    2. Ridgecrest, California is an isolated rural community located in the Indian Wells Valley of Kern County in the high desert, approximately120 miles north of Ontario and 120 miles east of Bakersfield. The Valley is formed by the Sierra Nevada Mountain Range. This natural wall of mountains surrounding the community, combined with distance to adjacent population centers, adds to the sense of isolation. The community is anchored economically by the China Lake Naval Weapons Base. The base, like many others nationally, has been drastically downsized through either direct layoffs or outsourcing of jobs. The effect on the economy of Ridgecrest has been dramatic. Significant population loss, reductions in tax base, job losses, and reduction in property values have occurred as a result of the base downsizing.

    The Ridgecrest service area population has declined by some 12.5% since 1990. This loss of population has impacted the health care delivery system through reductions in service utilization and less people being able afford to pay fully for services. There have been increasing numbers of Medi-Cal recipients, AFDC clients, and other indicators of a population growing increasingly poorer. Despite these declines, the economic condition of the Indian Wells Valley before the base reductions was so strong that factoring in these declines now makes the area comparable to what the State of California norm is for most socio-economic and demographic factors.

    The health care delivery system development prior to the implementation of DRIS Initiative was primarily provider driven, although there exists significant input from the community through the hospital governance model. The Ridgecrest Regional Hospital (RRH), a community non-profit hospital, has a corporate board of fifty community members who in turn select a nine member executive board. It is the executive board which has direct responsibility for oversight of the RRH. Four years ago the hospital began a planning process which involved the larger community corporate board. Board members were given a set of 5-6 questions. They were then asked to interview five people in the broader community to gain attitudes, beliefs and opinions. The responses from these interviews were incorporated into a strategic planning process which was subsequently implemented by RRH.

    Part of that strategic planning process led to the the hospital organizing and subsidizing the start-up of Sierra CommCare (SCC) in 1995. A non-profit community-based organization, SCC was organized to "develop locally managed and controlled health care programs that provide cost effective coverage for area residents". To accomplish this, SCC created a local provider network to contract directly with ERISA employers. The network includes RRH, one of two local physician groups, mental health professionals, chiropractors, pharmacies, and medical equipment suppliers. SCC has subcontracts with home health, speciality and tertiary providers not available in the local community. In addition, SCC contracts for claims processing and "stop loss" insurance on behalf of employers. As of March 1998, SCC had only one contract with RRH as a self-insured employer. The Indian Wells Valley was chosen as a DRIS site to support the integrated efforts already begun with the establishment of SCC.

    SCC was initially formed with the involvement of both local medical groups, employers and community leaders. In the Spring of 1997, as the DRIS Initiative was starting off, Drummond Medical Group, the local multi-specialty physician group, decided not to continue its involvement with SCC. The fact that providers were no longer cooperating in the development an integrated health care system in the Indian Wells Valley adversely impacted the progress of DRIS Initiative in the first year.

  2. Development of the Community Health Council

    3. Formation of the Indian Wells Valley Community Health Council (IWVCHC) began in April of 1997. Membership of the IWVCHC consisted of 22 individuals representing seniors, physicians, local government, the community health center, industry, retail, media, RRH, SCC, churches, schools, including the community college and other health care providers. The membership of the IWVCHC has remained fairly constant over the course of the first year of DRIS. Council attendance at meetings averaged 15 participants.

    The first meeting of the IWVCHC was July 7, 1997. In that first meeting, a number of concerns and expectations were elicited from the council members. Some of the concerns included: (1) the fact that providers in the community were not presently cooperating; (2) a doubt that a 20 member council could speak for the broader community; and (3) the fact that some members clearly did not want to endorse managed care or SCC in specific, as a function of managed care.

    To address the concerns regarding community representation and input, the IWVCHC agreed to involve greater numbers of residents through formation of select ten groups. Each council member selected a diverse group of ten people from within the community. These select ten members would serve as sounding board for generating ideas and responding to ideas generated by the IWVCHC. In addition, a community visioning meeting was held with over 150 attendees to gather responses to health care related concerns of the broader community.

    The character of the IWVCHC is marked by its assertiveness. The council members as a whole, are well educated. There is a core group which has consistently challenged the DRIS Initiative assumptions regarding the need to support the development of managed care in their community. The council strongly supports the improvement of the health resource delivery system and efforts to improve the health status of their community. However, why IWVCHC members have struggled with the value of pursuing integrated health systems development, has been due to the fact that: (1) The external threat to the community by outside managed care organizations has not been perceived by members of the IWVCHC as an immediate concern; (2) Many of the council members not involved in health services delivery, view managed care in a negative light; and (3) The economic issues in the region tend to have a greater hold on the attention and energy of the community, than matters of health care financing and delivery.

  3. Accomplishment of DRIS Learning Objectives

    4. The first major decision of the IWVCHC was to select the defined service area. Many of the council members felt that besides Ridgecrest and the smaller surrounding communities of Randsburg, Trona, Red Mountain, Inyokern, and Onyx, that Lone Pine should be included in the service area. To resolve the issue, the RRH’s patient origin data set was used as an effective means of evaluating patient utilization patterns for the service area. It was found that the hospital did not serve a significant portion of the Lone Pine population. As a result of this process, the IWVCHC decided to limit its service area to those communities where RRH had a significant market share (see Service Area Map, page 3, Section IV, Data Report).

    The next step undertaken was to define essential health system services. The IWVCHC used the Physician Provider Inventory and the Non-Physician Provider Inventory produced by the community assessment data consultant as the basis for discussion of essential community services. A brief overview of a health care delivery system with all its possible service components was discussed with the IWVCHC. In reviewing the local supply of services, the council noted that the Indian Wells Valley has an excellent scope of primary care and specialty services available. There are services needs however, which came out of the DRIS community assessment data analysis, that the council felt should be addressed. The list included: acute psychiatric services to assess patients in the emergency room; inpatient psychiatric care; drug and alcohol counseling; rehabilitation; out-patient mental health services; pulmonary medicine; and allergy services.

    Service components of the delivery system which were deemed essential included; disease prevention, health promotion, emergency services, primary care, multi-specialty care, acute inpatient care, tertiary care and long term care and rehabilitation. It was determined that tertiary care such as neonatal intensive care, invasive cardiology, and oncology would best be referred out of the service area.

    During the discussion of the health care system, it was pointed out that most health care provided today is managed care. Elements of managed care that are already operative but not integrated in the region are; utilization review, prior approval, health promotion, and financial risk for the cost of care. Since many of the council members disagree with the restrictions of managed care, such as lack of choice and care limitations, the council agreed to define managed care for the Indian Wells Valley to correspond to their values for health care service delivery. The IWVCHC adopted the description of managed care as " the most appropriate level of care provided at the most appropriate time".

    The IWVCHC understood that a cooperative vehicle had to be selected to implement programs in Phase II of the DRIS Initiative process. The cooperative vehicle had to be an organization which would have legal authority and be accountable for the distribution and control of health systems resources. The one major condition placed on the selection of the cooperative vehicle by the council, was that the entity be governed in such a manner as to reflect the goals and objectives of the IWVCHC.

  4. Description of the Process by which IWVCHC Selected Functions

    5. To assist the council in prioritizing functions for the development of a local integrated health services delivery system, a Forced-Choice Matrix Grid was utilized. The results of the DRIS community data assessment together with the two major qualitative assessments conducted during the early stages of the DRIS Initiative were placed into the Forced-Choice Matrix Grid and the council members were allowed to vote on their priorities. Two grids were used, one to look at outcomes which addressed the medical care delivery system the other to address community health promotion related activities. IWVCHC prioritized those functions that the majority of council members were willing to explore further. The top four functions voted on by the council were:

    • Provider Cooperation - To improve the cooperation between the Ridgecrest physician groups and with the local hospital.
    • Respiratory Clinical Pathway - To establish a case management, clinical pathway for respiratory patients to allow for cost effective, locally appropriate care to be provided.
    • Mental Health Clinical Pathway - To establish a case management, clinical pathway program for mental health and substance abuse patients to allow cost effective, locally appropriate service delivery to be provided.
    • Community Control - To create an informal Indian Wells Valley Service Area Health Care Authority to serve as a neutral arbitrator to assess and approve local health care system proposals against locally established criteria.

    The IWVCHC then agreed to form committees around each of the four potential function areas. The charge of the committees was to determine how well their selected issues fit the DRIS Initiative three-way test. The DRIS test asks that functions which can be implemented through the DRIS Initiative must be: 1) informed by data; 2) have community buy-in; and 3) better prepare the community for managed care. Additionally, each committee was responsible to define the proposed function or functions: (1) Activities - What will be done?; (2) Role of the Cooperative Vehicle - Who is responsible for implementation?; and (3) Feasibility - Can it be done?

Table of Contents


© CIRHM