DRIS Initiative Update

by Luisa Buada

The goal of the DRIS Initiative in year one has been successfully achieved through the completion of the following objectives at each of the five sites:

Development of a Community Health Council composed of representatives from the employer community, government, public health and behavioral health, hospital councils, community clinics, consumers, private physicians and hospitals.

Education to Council members regarding managed care in rural areas and the process and framework of the DRIS Initiative,

Analysis of each site's current status and potential development through a community health assessment, employer insurance survey, and market 'snapshot' (the latter only for sites considering the development of a financial vehicle), and

Development of an appropriate scope of essential services for each community.
In the fourth quarter of grant year one, the challenge before the Community Health Councils will be to choose either an integrated health service delivery and/or financing function/s and to explore those functions for potential feasibility. Each site will also need to reach consensus on whether to create a Cooperative Vehicle that focuses on integrated health service delivery only or one that incorporates a financing component.

We have found in grant year one that each DRIS site has its own pace for accomplishing the DRIS objectives due to unique community needs and issues. In recognition of these realities, greater flexibility was required to allow some sites to move toward completing their community assessments and choosing potential integrated service delivery or financing functions over a fifteen to eighteen month time frame instead of twelve months. On the other hand, other sites we anticipate may not only complete grant year one objectives as planned, but also proceed on to implementation of their service delivery or financing functions (a grant year three expectation) before the end of grant year two. Therefore, the DRIS Initiative process was modified from three grant years to three Phases:

Phase I, establishment of councils, community assessment and selection of functions
Phase II, establishment or selection of a Cooperative Vehicle and feasibility analysis
Phase III, implementation and financing

The principal benchmark for Phase II is the establishment or selection of a Cooperative Vehicle. The decision to utilize a Cooperative Vehicle to accomplish the chosen scope of functions will require the Community Health Councils to achieve a full understanding of the local market place, the effects of market reform on rural communities and appropriate models of collaboration. The Councils may choose an existing community non-profit organization or can develop a new corporation from the membership of the DRIS Community Health Council.

The purpose of the Cooperative Vehicle is to perform a managed care related function which will assure access, and/or ensure quality and/or contain costs through an integrated network of providers. The Community Health Council needs to ask and answer the question: for what function will the integrated network assume responsibility? At the minimum, the entity, keeping an eye on the essential characteristics of a rural integrated system (described in the prior newsletter), would choose to focus on ensuring quality. Some examples might be:

implement a local case management system that works with health plan payors, the local physicians and hospital network to reduce hospitalization days,

manage the housing, social service and mental health needs of frail and chronically ill elders in the community to keep them well and independent in conjunction with Medicare managed care plans, or

provide coordination of care and health care management to high users of health services.
With an epidemiological perspective, the Cooperative Vehicle could develop a mental health clinical pathway to be implemented through a network of primary care and mental health providers which would provide guidance for managing patients with mental health diagnosis, in order to reduce the incidence of inpatient psychiatric and emergency room visits.

The community might elect to place more control in the hands of the Cooperative Vehicle over local health care decisions. For example, the Community Health Council could create or select a community controlled administrative entity to monitor quality and utilization of health plan members who are cared for within the local integrated provider network. The entity might also handle billing and claims administration. As an outcome of keeping dollars local in the community, the entity could have as its goal to use surplus dollars to underwrite the implementation of an affordable health benefit package for employees of small businesses.

Whether DRIS sites choose to incorporate their Community Health Councils to be their Cooperative Vehicle or select an existing organization, the issue of governance, structure and membership necessary for carrying out the chosen service delivery system and/or financing vehicle functions will need to be defined. Councils will have to determine how they will exert or maintain control over decisions related to access, local resource allocation and health outcome measurements. For sites adding a financing component, they will need to explore the potential for selling their product locally to employers and consumers alike. Because this activity requires negotiation of power, control and authority over health care decisions for the entire community, Council members will have to go beyond their group and obtain buy-in from individual stakeholders in the community who may not be at the table.

Once the community has decided on the functions and governance of the Cooperative Vehicle, it will need to study the feasibility of implementing those functions. The feasibility study will look at issues such as:

How can clinical resources best be coordinated by the Cooperative Vehicle in order for the community to assure access and allow for appropriate quality assurance?

What implementation strategies must a Cooperative Vehicle consider in order to be capable of providing a structure which can limit duplication and lower costs?

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