CHALLENGES OF AUTOMATING AN INTEGRATED PROVIDER NETWORK

 
By Bruce W. Johnson, M.S. and Steve Schafer, M.Div.
 

There are a variety of ways that providers can align themselves with one another to develop a strategic advantage in the market place. These strategic alliances are becoming more important as managed care organizations are looking to contract with a single entity that represents a network of vertically integrated providers. These arrangements are particularly attractive since they offer their enrollees a continuity of care and the managed care organization needs only to sign one contract for all participants in the network.

The vertically integrated network offers the additional advantage of delivering a full spectrum of services from inpatient to outpatient programs, in a variety of settings at any levels of service. Few organizations can provide all of these programs and services equally as well. Consequently, many providers are forming strategic alliances and creating functional service networks. When multiple organizations are integrated into a single network there are additional data processing requirements over and above that required by an individual provider.

Client Registration:

Since a gatekeeper may refer a patient to a therapist in any one of a number of the participating organizations, it is advantageous to have a direct communications link connecting all of the entities. Communication and coordination are facilitated if a central access point coordinates referrals and starts the registration process with a telephone interview. The data collected should be entered directly into the computer while the caller is on the phone.

Scheduling:

The other function that needs to be shared among all participants in a network is the ability to check and schedule appointments. If a central access point is used to coordinate intakes, the staff member should have access to a centralized scheduling system so that the schedules can be checked and appointments made for all therapists in the network.

Patient Tracking:

A centralized system should be designed with a common database and a single master patient index. One unique case number should be assigned and used by all providers. With a common database that can be accessed from all locations, the intake worker or case manager can begin the patient registration process during the initial telephone interview. This information will then be immediately available at any location. The use of a centralized access point and a coordinated staff and patient database will simplify the registration process and improve access to the provider network.

Utilization Management:

If the case manager at the central access point is also authorizing services, he will need on-line access to utilization criteria, carrier contract information, benefits, prior treatment, and some limited clinical information. He will also need to check on present authorizations and any service limits. Access to a central database of providers and their staff with credential information is also useful for case assignments.

System Design Considerations:

Implicit in the design of an integrated management information system is the ability to all of the providers to effectively communicate with one another through the use of common software and/or by the development of standard interfaces. To facilitate this process, providers must agree on standards for the content and format of their key internal and external reports, medical record forms, intake process, billing codes, admission, continuing care, and discharge criteria, treatment protocols, treatment plans, assessments, progress notes, discharge plans, etc.

The service system members will also need to develop a set of policies and procedures that address membership, operations, quality assurance / performance improvement, marketing, consumer rights, consumer and member grievances, and oversight. This is particularly challenging since there are no nationally recognized standards for behavioral healthcare information systems that would serve this purpose.

Performance Improvement / Quality Assurance:

The members of the network should also develop and agree to performance improvement standards for each member provider as well as for the network as a whole.

Some major elements to consider in a Quality Improvement program for an integrated service system include:

  • Clinically appropriate and equitable assignment of clients by all network staff to the appropriate level of care
  • Clinically appropriate assignment of lengths of stay
  • Decrease in recidivism
  • Decrease in recidivism among acute psychiatric inpatient clients where appropriate
  • Increase accessibility and consequent client enrollment
  • Assure client satisfaction with the quality, timeliness and appropriateness of services arranged for by the network
  • Assure provider satisfaction with network performance
  • Develop an appeals process for consumers and providers
  • Develop an appeals process for consumers and providers
  • Monitor the utilization of services, including the distribution of referrals among providers and the use of high-cost resources.
  • Evaluate competency and performance of providers in the network
  • Track mean discharge Length of Stay (for clients who left the Level of Care during the report period)
  • Track mean active Length of Stay (for clients still active in the Level of Care at the end of the report period)
  • Track total services authorized
  • Track total services used
  • Track total payments for services
  • Track unit cost of services (calculated as the total payments divided by the total services used)
  • Track time interval from the initial phone call (or walk in) requesting service to the first face-to-face contact in the assigned Level of Care
  • Measures are calculated separately for emergency care, urgent care, and non-urgent care
  • Expand urgent care information to create a category of clients for whom delay in getting started in services (in the appropriate Level of Care) would significantly reduce the likelihood that they would engage in services at all
  • Track the mean length of time from request for service to first contact in the approved Level of Care
  • Track the median length of time from request for service to first contact in the approved Level of Care
  • Track drop out rates by provider and in aggregate
  • Measure the effectiveness of transitions from one level of care to another using the amounts of time clients spend between services and the drop out rate.
  • Report aggregate statistics on the length of time between services are generated separately for each provider-level of Care combination based on the provider and the Level of Care the client is transitioning to. These statistics include the mean and median length of time.
  • Provide further aggregates statistics across Levels of Care and Level of Care across providers.
  • Monitor recidivism by diagnosis, age group, gender, severity, and previous history

Community Health Information Networks:

The availability of a Community Health Information Network (CHIN) would be a distinct advantage in linking providers in a network. A CHIN is a set of policies, procedures, protocols and data formats that are agreed upon by the participants for the express purpose of exchanging data. This infrastructure would then provide the vehicle by which the standardized patient data are exchanged.

About The Authors:

Bruce Johnson, M.S., PMP, is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with social service, healthcare, and government organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcsinc@fuse.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.