Community- and Population-Based Health Care Delivery Systems:

Building Collaborative Networks

Regional Health Care Safety Net SummitHealth and Medicine Policy Research Group

Pat Terrell

June, 2009

Building Regional, Collaborative Health Care Networks

• Why?– Pressure will mount on local

communities and governments to meet growing need

– Publics can’t meet need alone– Providers motivated to come to the

table to bring new ideas– National—and state--reform will

require new delivery system models

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Local Communities Have Unique Opportunities

• Rising numbers of uninsured likely• State is just trying to get through the day

in face of growing deficits (Medicaid)• Federal government will be immersed in

reform deliberation (looking models for addressing both access and cost)

• Any new approach will require new delivery models (“Coverage” is not the same as “Access”)

• Local communities can become learning laboratories for new delivery systems with local government as “honest broker”

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Elements of Developing Effective Delivery Systems1. Know the population.2. Understand need and current health

utilization of all levels of care.3. Find gaps/duplications in continuum.4. Align mission, financial sustainability,

competencies of individual providers.5. Create systems to manage network.

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Who is the focus of a safety net system?Hospitals? Doctors?

Unions?

County Supervisors?

Population!

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Targeting Population

• Underserved, not just uninsured– Medicaid– Multiple morbidities (including pysch)– Geographically isolated– Under-insured – Immigration/cultural issues

• Where do they live now and where are they moving?

• What care are they getting now and from which providers (FQHCs, EDs, hospitals, doctors, nursing homes, etc.)?

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Population: What do they need?• Must assume what demand should

be, not just what is.• Population focus to determine

volume of:– Primary Care– Specialty Outpatient Care– Inpatient acute– Lower levels of acute– LTC

• Translate into provider requirements.

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Different Approaches to Determining Need

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Building a System: Filling Gaps, Eliminating Duplication• After mapping out need and current

resources, identify:– Current gaps and duplications– Inappropriate utilization– Project future concerns about delivery

system ability to meet need.• Begin fitting providers to system

design, based on:– Individual institutional mission– Financial rationality (i.e., primary care in

FQHCs)– Community benefit leverage– Not wanting to be “left out”

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Bringing Players to the Table• Start with individual discussions

(even if within public system only)• Propose roles, assure that others

are included• Key issues: predictability,

sustainability, equitability• Stress role of local government

bodies as “honest brokers”• Bring all together when there is

general agreement to endorse broader plan

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Managing the Network

• Network management will be key – takes beyond a puzzle of different components

• IT, referral systems, common disease management approach are essential

• Connections with non-acute services

• Evaluating what works and what doesn’t (and changing it) on an ongoing basis is critical

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Formalizing the Network

• Can be internal system oversight or multi-provider “governance”

• Accountability of all elements of the system to each other is important

• Planning for continual changes in the patient population and service needs to be key function

• Resource sharing and cost-saving is a standing agenda item

• Coordinated advocacy at state and national level is a significant benefit

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Network Development Focused on Underserved Populations: Examples• California Counties (unique requirement

for local responsibility for indigent care)- San Mateo- Orange

• New Orleans (4 parishes)• Austin, Texas (greater Travis County)• Chicago/South Suburbs (Comer

Plan/CHNU)• Miami/Dade County• Cincinnati/Hamilton County Plan