When San Francisco-based Chinese Community Health Plan (CCHP) (www.cchphmo.com) needed to enhance its care management initiatives for more than 31,000 commercial, Medicare and third-party administrator (TPA) members, they turned to DST Health Solutions' dynamic duo—Care Analyzer and CareConnect, the foundations of DST's Integrated Care Management (ICM) Suite. This innovative combination gave CCHP the ability to identify and prioritize members most in need of care, provide timely interventions, and perform systematic evaluations to ensure the best member outcomes. Most impressively, DST had the system up and running in just six months, including the implementation of a Nurse Advice Line to meet an urgent state mandate.
BUILDING A RICH LEGACY ::
CCHP has its roots in San Francisco's historic Chinatown, where community leaders first built a dispensary over a hundred years ago and later a hospital to offer Western medicine to local residents. Several decades later, CCHP was formed to provide and administer health plan services in an increasingly complex organization designed to deliver culturally sensitive, linguistically appropriate care to community residents like Mei Cheng*.
Today, the plan has 31,000 members, with 15,000 covered under CCHP and 18,000 covered under TPA services performed by CCHP for its hospital and IPA partners. Because care is provided by independent physicians without a vertically integrated medical group, documentation and sharing of information across specialties has been a significant challenge—until now.
"Through an end-to-end ICM platform, DST has given us a way to continue delivering high-quality, affordable medical services and resources to the community," says Larry Loo, CCHP's Director of Business Development and Operations. "We needed a solution that could both control cost and improve data integration, while at the same time, giving us the flexibility to meet challenges like the state's mandate for timely access to care. And in just six months, ICM gave us the total package."
|"The ICM Suite has given us the ability to identify at-risk populations, place those populations into an appropriate care management program, and develop planned interventions that focus on the best outcomes for our members." –Larry Loo,
Director of Business Development & Operations,
Chinese Community Health Plan
NEW SYSTEM, NEW CAPABILITIES ::
Offering a 360-degree view of all members, ICM provides the insight required to properly manage populations, effectively utilize benefits, and provide education for optimal self-management. The cornerstones of the ICM Suite are DSTHS CareAnalyzer® for member identification and CareConnect for care management and integration of multiple claims administration platforms, including the PowerMHC Claims platform used by CCHP. In addition, the ICM Suite leverages The Johns Hopkins Adjusted Clinical Groups (ACG) predictive model, which identifies gaps in care, as well as members who have the greatest opportunity to improve health outcomes. For many health plans, these applications must be supported separately on multiple legacy processing systems.
"The real-time integration definitely adds value," says Loo. "The ICM Suite has given us the ability to identify at-risk populations, place those populations into an appropriate care management program, and develop planned interventions that focus on the best outcomes for our members. Real-time integration with our claims administrative system, DST's PowerMHC® system allows our care management staff to perform their care management responsibilities utilizing the most current eligibility, provider, and benefit information available on a member. This helps us ensure a greater level of both member and provider satisfaction."
All CCHP team members now rely on CareConnect to identify, call and follow-up with members who qualify for one of five available disease management programs: CAD, CHF, COPD, Diabetes and Hypertension. Based on health risk appraisals facilitated via CareConnect, CCHP team members can assign patients to one of three categories to determine which actions to take during follow-up. CareConnect can also track a member's response to health risk appraisals to measure and compare them over a set period of time.
For Mei Cheng, that means that not only is she identified via CareAnalyzer and Johns Hopkins ACG System as a good candidate for targeted care management of her diabetes, but also that her case manager (via CareConnect) regularly reaches out to her to offer help with diabetes management, medication adherence, and blood-sugar testing. In addition, by using the diabetes HEDIS measures, Mei's case manager is ensuring that potential gaps in care are avoided by following up with Mei to ensure that she understands and receives services such as HbA1C testing, eye exams, and LDL-C screening, as well as routine blood pressure monitoring and kidney function tests.
A SMOOTH TRANSITION ::
After CCHP first determined that their old system no longer met the needs to perform required care, disease and chronic care management, they looked for a vendor that could work with its multiple line of business—Medicare, commercial and TPA—while having the flexibility to meet more immediate needs, like the state-mandated 24-hour timely access requirements. DST responded to this challenge with a streamlined implementation process that allowed just six months to bring online both the total ICM solution and the 24 hour Nurse Advice Line.
"Implementation was very aggressive," says Loo. "We had to make sure that the administrative systems were up by a certain date, and ensure that we met the state's timely access requirements with a 24 hour Nurse Line to be active by January 2, 2011. At the same time, we had to integrate clinical content, case and chronic and disease management programs with our core claims platform."
Ultimately, Loo says CCHP was impressed by both DST's implementation process and the affordability of the solution. CCHP was able to successfully orchestrate the implementation over the planned three- to six-month timeframe by using a small group of plan professional augmented by the DST staff. In addition, DST professionals created specialized scripting for the 24 hour Nurse Advice Line that integrated educational content from a specialized content vendor and conducted training sessions using the new scripts.
LESSONS LEARNED ::
Real-time integration between claims administration and care management is an imperative for health plans. Loo offers these recommendations for success:
- Understand your real clinical, business and financial needs as opposed to just checking boxes on a list of features.
- Look beyond the data requirements and understand the real information that you need. Then choose the best source for accessing and managing that information.
- Understand how and how fast data and information will flow, so you're better positioned to achieve real-time access and updates.
- Make sure the system has the capacity to address specific goals, such as increases in Medicare Star ratings or other performance improvements.
- Search for clinical content if you lack the resources to develop it in-house. Make sure protocols are aligned with content to allow for rapid implementation.
- Empower the right person or a small team of people to orchestrate implementation, while relying on vendors to support training and perform other tasks.
- Work for full integration between the health plan and providers, ensuring that members, physicians and nurses can easily use and make recommendations through the system.
- Move beyond mandates. While California requires that health plan members speak to a live person within 30 minutes, other variables, including language and culture, are equally important in meeting a member's needs.
REAPING THE BENEFITS ::
For CCHP, the contrast between the old system and ICM is impressive, with CCHP already improving its Medicare Star Ratings (www.medicarestarratings.com) a quarter point since moving to the new system. In addition, Loo predicts higher usage of CCHP's Chinese Community Health Resource Center, which offers health promotion and outreach through Chinese and English courses and pre-and post-measurements of health status. His long-term goal is to fully integrate CCHCRC programs with other wellness and fitness offerings, giving nurses the opportunity to move away from paper spreadsheets to fast, telephone-based enrollment and automated member tracking.
"CCHP is committed to serving our community and is devoted to delivering the highest quality health plan to the people and organizations we serve," says Loo. "Through our integration with DST, we now have the enhanced capacity to deliver quality, affordable medical services and resources."
And for members like Mei Cheng, that's all good news.::
*Ms. Cheng's name has been changed to maintain confidentiality.
ABOUT CHINESE COMMUNITY HEALTH PLAN
CCHP is the health plan subsidiary of Chinese Hospital in San Francisco. For nearly 25 years, CCHP has provided culturally competent and linguistically appropriate care to a community that is generally not served by the broader health insurance market. CCHP provides quality, affordable coverage for large and small employer groups, individual and families and people with Medicare. CCHP is contracted with Medicare to offer Medicare Advantage plans, including Part D. CCHP is open to everyone in San Francisco and Northern San Mateo Counties.
For more information, contact Larry Loo, Director of Business Development and Operations, at (415) 955-8800 or
For more about DST Health Solutions, contact
us at firstname.lastname@example.org.