About the DRIS Initiative

In response to the rapidly changing health care environment, The James Irvine Foundation launched a four year six million dollar rural health initiative for the development of integrated health systems.

The Initiative for Developing Rural Integrated Systems (DRIS) is designed to support a community-based dialogue and planning process that results in the creation of integrated health systems at each participating site. The primary value of the DRIS Initiative is that it provides rural communities an opportunity to examine their health care delivery system using a structured framework.

DRIS is different from most grant programs in several respects. DRIS uses a "systems" approach to change and engages a broad cross-section of the community, including providers, employers, community leaders, and others in an inclusive dialogue and planning process. The DRIS approach relies on community-specific data to steer decision making. Based on the data, the project sites select a managed care strategy.

At each site, local leaders form a Community Health Council that meets regularly to assess the existing health system and the overall quality of health in the community. The Council's role is to determine and in some instances advise as to the appropriate scope of services for the community, the appropriate mix of providers to deliver those services, and the arrangements for a single accountable entity that will ensure a full continuum of care to its residents and assume risk.

DRIS does not award grant funding directly to participating communities. Instead, sites are provided with extensive technical assistance resources, including expert consultants in managed care systems development, market analysis, community facilitation, data collection, and legal analysis. These consultants act as neutral facilitators in the decision-making process, providing technical assistance and expertise without direct involvement in local politics or the private agendas of participants. DRIS also covers the costs at each site of a full-time Local Coordinator and related office operations.

Funding that DRIS sites receive directly are through "milestone grants," which are awarded as sites achieve specific project outcomes. For implementation, each DRIS site is eligible to receive up to $200,000. The use of specific funding parameters and milestone grants is intended to help resolve conflicts, advance integration efforts, and sustain the volunteer community efforts.

The DRIS Initiative is based on several key assumptions:

1. Health care is a local product: Decisions about the development and delivery of health services need to be controlled at the local level.
2. Rural health care is not miniature urban health care: Solving rural health problems by trying to downsize urban models will not work.
3. Development of delivery systems that integrate local resources is essential: Creating a system that can survive competitive market forces and maintain local access to health care services necessitates integration at the local level.
4. Community planning and involvement in health care decision-making is critical: Community leadership is essential to determining what services will remain local and how the health services will be provided in their community.

DRIS Project Management

DRIS is being administered by the California Institute for Rural Health Management (CIRHM), a non-profit organization based in Oakland, California. The Initiative is supported by the DRIS Advisory Committee which is composed of representatives knowledgeable in rural health issues.

CIRHM ensures overall program coordination and technical support to the DRIS Initiative through four core functions:

• by providing or arranging for technical assistance and education;
• by facilitating the creation and implementation of integrated delivery systems;
• by encouraging cross-fertilization of ideas across project sites; and
• by disseminating learning to the field.

An independent evaluation of the DRIS Initiative is being conducted by Ira Moscovice, Director of the Rural Health Research Center at the University of Minnesota. Success in the DRIS Initiative is being measured by increased integration and coordination of health care services and increased retention of health care expenditures in the rural communities.

Background: Managed Care in Rural Communities

Until recently, managed care has not been considered a viable option for rural communities. Given their narrow population and economic base, rural communities have lacked the volume for the cost-effective management of health care required under managed care systems. As a result, providers in rural areas have been only peripherally influenced by changes in health care financing, continuing to operate comfortably under fee-for-service or cost-based reimbursement systems. The status quo, however, is no longer tenable for rural communities because market forces and government initiatives, among other factors, are forcing change on the existing systems of organization and financing of health care. As both the public and private sectors shift to systems of managed care and other strategies for controlling health care costs, rural communities must also proactively respond to this new management and financial environment.

In those rural communities that fail to adjust to the changing insurance environment, it is likely that its residents will be unable to consume health care locally and will be obligated to travel long distances to urban areas for their health care, thereby creating adverse consequences for the rural economy. The impact of the health care system on rural economic development can be considerable. Directly health care providers and services generate local jobs and income. Indirectly, accessible health care services of high quality, aid the rural economy by attracting and retaining residents and business' by generating investment funds and by contributing to local leadership capacity.

Rural communities face two significant issues as managed care becomes focused on the rural delivery system. Given that the rural delivery system's major task is to serve as an access point for all levels of care, how can this responsibility mesh with managed care plan's emphasis on controlling utilization? Where will the locus of control of utilization lie; internally with a local integrated provider network or externally? The major problem presented by shifting responsibility for utilization to external sources is that access to care may become limited for the whole community. Rural communities have found that an integrated approach with local control of utilization, can be helpful in assuring the availability of a reasonable level of health care while meshing positively with the goals of managed care.

What is an "Integrated Health System"?

"Integrated health systems," "networks," and "strategic alliances" are similar terms that refer to formal, legal arrangements that use resources and/or governance structures from more than one existing independent provider to meet common goals and objectives. In a rural health care context, an integrated health system that has the goal of ensuring adequate access to quality care for a given population or area must demonstrate the following characteristics:

1. The system must be built on essential services defined by the community rather than by an external entity such as a managed care plan.
2. The community to be served must be defined. Depending on its size, the system may be population-based or service-area based.
3. Services that are provided locally must be framed by the epidemiology of the community.
4. Prevention and early intervention must be essential components of the system.
5. Advanced levels of care must be provided through formal linkages with external resources, rather than addressed independently by each practitioner.
6. To ensure that priority is given to community needs rather than to clinical or institutional interests, outcome measures should be community-oriented as well as disease-based.
7. To ensure cost-effective and appropriate access to care, there must be a single accountable entity that manages local health care resources and assumes risk.

Based on the above characteristics, integrated health systems offer several community benefits:

• better coordination of health care
• a focus on health promotion and preventive care
• increased access to specialty services and relevant technologies
• the reduction of unnecessary duplication in clinical and management capacity
• increased retention of health care expenditures in the rural community

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