Sandra Hewett, director of care management at Community Health Plan, was charged with overseeing the implementation of the organization's integrated care-management software solution.

The continued use of manual processes raised a real concern for program changes and tracking with newer and more robust state and federal regulations.

Community Health Plan (CHP) in Washington faced several challenges that needed to be addressed in order to achieve its goal of deploying a patient-centric delegated care-management system. For years, care managers at CHP used multiple, disparate systems for case management (CM), disease management (DM) and utilization management (UM) — resulting in information silos. Without an integrated system, there
was a lack of evidence-based clinical pathways to ensure consistent care planning and management of patients. As a result, data collection was not robust, tracking was inadequate and reporting was not streamlined.

In keeping with its vision and to meet organizational needs, CHP decided to deploy a patient-centric care-management system that emphasized collaboration between care managers, members and physicians, supporting the medical home philosophy. CHP envisioned the future deployment of a delegated care-management service model, where the primary physicians in its community health centers would actively participate in and/or lead patient care management.

“The manual systems — some paper-based — created inefficiencies, lowered data integrity and decreased coordination of care for the patient,” says Sandra Hewett, director of care management at CHP. “In UM, time-consuming audits for continuity and coordination of care reporting led to inaccuracies due to manual processing. Management of patient records in a manual-processing environment was inefficient and led to the potential risk of lost paper files as medical records were transferred between departments. It was also clear to everyone the current manual processes would not scale effectively as our organizational needs and programs grew.”

CHP was created in 1992 by a group of community health centers across Washington state. The state-wide health plan provides coverage for people in 33 Washington counties, delivering services to members through more than 300 primary care sites, 90 hospitals and 8,000 specialists. Overall, CHP offers access to locally delivered treatment and services for more than 240,000 individuals.

The continued use of manual processes raised a real concern for program changes and tracking with newer and more robust state and federal regulations, Hewett explains. “We realized that if we continued with a manual system, we would face potential risk with data integrity issues and the inability to produce comprehensive reporting. In preparing for increased regulatory requirements and accreditation plans, we concluded that increased integration between UM, CM and DM were imperative.”

CHP was also cognizant of the need to meet the new HIPAA regulations, and the need for robust tracking and reporting capabilities when it pursued National Committee for Quality Assurance (NCQA) accreditation in 2010.

Recruitment takes a role

Given the nationwide shortage of nurses, CHP, like other organizations, also faced the challenges of recruiting and retaining qualified RN staff. Moreover, the lack of efficient integrated information systems further exacerbated the difficultly in recruiting, training and retaining nursing staff, while further adding to the annual operating costs. These issues loomed large as the health plan looked toward future expansion, which would require better connection and integration.

The CHP team concluded the organization would need a patient-centric care-management platform that would: integrate its work flows, such as UM, CM, DM, appeals and grievances, across all lines of business; be configurable to enable CHP to meet not only current, but also future business requirements; provide robust data collection, tracking and reporting; increase efficiencies and reduce errors through automation; enable CHP to comply with the various regulatory and accreditation requirements; and be intuitive and easy to learn and use.

After a thorough evaluation of leading solutions, CHP selected Jiva, an integrated care-management software solution from ZeOmega. Hewett was charged with overseeing the implementation. In 2008, CHP deployed Jiva's integrated UM, CM, DM, appeals and grievances work flows centered on an assessment-driven care plan.

“We used Jiva to aggregate data such as claims and pharmacy from other systems and integrate evidence-based guidelines into its decision-making processes, as well as influencing case-finding activities,” says Hewett.

In a second phase in 2009, CHP introduced additional features that fine-tuned its system and optimized work flow.

Through Jiva, CHP was able to integrate information across claims, labs, pharmacy and other internal systems and across different work flows. CHP staff is now able to see a consolidated view of patient information. CHP also achieved its goal of deploying a patient-centric care-management solution, enabling care managers, providers and other stakeholders access to patient information from multiple points. This allowed clinicians to access and complete patient information with real-time data. Through Jiva, they were able to use integrated evidence-based guidelines during the decision-making process, thereby ensuring consistency in the application of benefit determinations. As a result, CHP continues to see improved patient care and outcomes.

According to Hewett, Jiva enabled CHP to realize significant efficiencies through its streamlined work flows, business rules-driven processes, and automated/scheduled reporting and correspondence, as well as other capabilities such as alerts and schedulers.

Improved efficiency, cost savings

Prior to deployment, CHP performed a detailed analysis that established expected cost savings and efficiency gains from deploying the software. According to Hewett, an increase in case-management efficiency of 30 percent has yielded a corresponding increase in referrals to case management. This has resulted in more proactive management of patients' needs, she says.

Utilization management also saw an increase in productivity and improvements in turnaround times, Hewett reports, as CHP increased its utilization-management efficiencies with a 47 percent increase in its caseload per full-time equivalents.

CHP realized further gains in February 2009 when it implemented batch integration between its external claims processor and Jiva. The additional integration allowed CHP to further increase the number of cases handled by case managers by 25 percent. A similar percentage increase was noted in the number of UM reviews completed by the CHP staff.

CHP was able to integrate information across claims, labs, pharmacy and other internal systems and across different work flows. CHP staff is now able to see a consolidated view of patient information.

“We realized additional benefits in areas of employee productivity and expanded market presence,” Hewett says. “Because Jiva is a Web-based integrated care-management platform, we are now able to provide secure access for staff to CM, DM, UM and other patient information through our Web browser from a remote location. This has created remote work opportunities for care-management staff, thereby improving employee satisfaction.”

This remote-access capability also led to the launch of a satellite CHP office in Spokane, expanding the health plan's customer service to both members and providers. Additionally, the satellite office strengthened CHP's already tight linkage to its community health centers, Hewett says, thus strengthening a key strategic goal of the health plan.

“We were able to transform our fragmented care-management environment into a proactive, connected healthcare ecosystem,” she says. “Real-time access to member health-risk assessments, clinical pathways and other patient information enabled us to more quickly identify at-risk members and create customized care plans and management strategies, reducing medical costs and enhancing outcomes.”

CHP plans to offer its vision of a delegated care-management service model at its community health centers by deploying the Jiva Provider Portal in early 2010. “The portal will allow the patient's entire healthcare team, across the provider network, to collaborate and participate in the management of the patient; enhancing the patient experience, improving the health of our population and reducing preventable medical expenses,” says Hewett.

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