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In 2006, CHE launched a system-wide strategic planning process that challenged stakeholders across the system to envision the future of health care in the year 2017. Within this Strategic Plan, CHE articulates its strong commitment to move forward with a care management strategy. In CHE’s ideal future health care system, care is tailored to the individual’s needs and current conditions and is coordinated throughout their life cycle and across the continuum of care. Patients receive care that is consistent, convenient, compassionate and safe; and they are able to make highly informed decisions regarding their health care based on accurate information, unbiased advice and personal preference. Skilled teams of providers working in effective and efficient systems will help patients optimize their health through education, advice, reminder systems, accurate record keeping and therapeutic interventions. The goal is to optimize each individual’s health potential through informed decision-making, effective communication and process facilitation, resulting in the right care delivered in the right setting at the right time. Such a model calls for a dramatic transformation in the way care is delivered and requires properly aligned financial incentives and interoperable, electronic personal health care records – owned by the individual and kept secure and available for their use. This will only be effective if the interests of the patients are placed ahead of the interests of physicians, hospitals, health care systems and payers. This large scale, system-wide transformation initiative will evolve over several years and is organized into four phases: In-House RHC restructuring focusing on hospital-based case management; enabling initiatives extending beyond acute care; integrated community approaches to include local provider, social and/or faith based organizations; and regionalized strategies across RHCs to support and leverage system-wide approaches for care management. The Comprehensive Care Management initiative was launched in early 2008. The planning and start-up activities were completed which included the development of a project leadership structure including team membership with roles and responsibilities, guiding principles, overall project approach and timeline.
The Hospital-Based Case Management phase of this initiative is well underway. This phase is linked initially to the foundational activity of implementing the MIDAS+ software across CHE hospitals. The successful implementation of a clinical tool such as MIDAS+ requires a transformation of the hospital case management department processes that will then be enabled by the technology support. The goals of the HCM transformation include the development of a model that is collaborative, data driven and outcomes focused; is designed from a comprehensive view considering clinical, financial, psychosocial and spiritual needs of each patient; and integrates the functions of care coordination, discharge management and utilization management. The case management functional team, comprised of directors and/or managers from each hospital, is leading the transformation efforts at each RHC. A comprehensive current state assessment was completed in May which included a detailed description of the infrastructure, functions, processes, roles and responsibilities and outcomes data for case management at each hospital. The assessment highlighted leading practices and strengths as well as opportunities for improvement. Following the current state assessment, the team came together in July to design the model for hospital case management for the future state. In order to test various aspects of the CHE Care Management model, three pilot programs have been identified and are now in various stages of planning and implementation. Pilot A focuses on linking a comprehensive care management approach to a targeted Medicaid patient population served by Mercy Health System of Southeastern Pennsylvania (MHS) and Keystone Mercy Health Plan (KMHP). The goal is to redesign the process of care and align incentives to promote care coordination, optimize patient health outcomes and improve the efficiency of the delivery system. Pilot B focuses on expanding the unique relationship between St. Peter’s Health Care Services and the independent CHOICES (Case management Helping Older adults maintain Independence with Comprehensive Effective Services) Program. CHOICES is a geriatric care management program for adults age 60 and over who live in the Albany, N.Y., community. The underlying premise of the program is that providing patients with the tools and services they need to remain in their own homes for as long as possible can reduce the cost to both the individual and society. Consistent with CHE’s Comprehensive Care Management Model, the CHOICES program ensures that clients get the right care, at the right time, in the right setting. Pilot C, the Sisters of Providence Health System / Physician Integration Model, will focus on the potential for expanding the care management infrastructure developed at Mercy Medical Center in Springfield, Mass. Discussions are underway related to the potential for incorporating the lessons learned from managing this Medicare population into the care management of other patient groups. In summary, CHE’s Comprehensive Care Management initiative will build the infrastructure and systems to help connect individuals with information to make informed decisions about providers, services and programs that support their holistic and spiritual needs throughout their lives. The implications for this new health delivery model – including the restructuring of services into a “Hub” to allow for better coordination and planning; the introduction of enabling connectivity; the creation of community networks across the continuum of care; and opportunities for regional collaboration among RHCs – are significant. I thank you all for your creativity, energy and support as we embark on this journey to continue to be a transforming, healing presence in the communities we serve.
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