Health System Redesign Initiative Implementation Update March, 2008 - October 15, 2008
Background
On March 25, 2008, the Board of Supervisors approved a first-year implementation plan for the Health System Redesign Initiative (Redesign), which has the following overall charge:
Within two years, design and implement a new, sustainable and creative approach to healthcare delivery that incorporates key recommendations of the HMA Phase 2 Final Report and the recommendations of the Blue Ribbon Task Force (BRTF) on Adult Health Care Coverage Expansion.
Led by the County Manager, this initiative’s core staff team includes: Sang-ick Chang, CEO, San Mateo Medical Center (SMMC); Susan Ehrlich, Chief Medical Officer, San Mateo Medical Center; Charlene Silva, Interim Chief, San Mateo County Health System; Maya Altman, Executive Director, Health Plan of San Mateo (HPSM); and Srija Srinivasan, Special Assistant to the County Manager for the Redesign initiative.
The Redesign team committed to bring an update to the Board of Supervisors in October 2008, to relay the six-month status of this effort. This document summarizes the progress achieved within the seven priority areas (noted below) targeted by the Redesign effort, as well as challenges and next steps for moving forward.
Discussion
As outlined in the Implementation Plan accepted by the BOS in March, the Redesign initiative identified seven areas of priority focus:
1)	Eligibility and Administration;
2)	Chronic Disease Management and Care Coordination;
3)	Integration Across Levels of Care;
4)	Physician Leadership, Structures, and Accountability;
5)	Community Health Network for the Underserved;
6)	Long-Term Care; and
7)	Strategic and Operational Financial Improvement.
Within each priority area, the Redesign Team developed goals and first-year activities aimed at improving healthcare access and coordination of the clients we serve, as well as improving the County’s financial position in healthcare delivery. Listed below are the overall goals and key milestones achieved during the first six months of Redesign. Attachment 1 provides a status update on each of the activities targeted during the March through October 15 timeframe.
Eligibility and Administration
Overall Goals:
●	Maximized enrollment of, and retention in, public health insurance/ coverage programs with emphasis, in the first year, on Medi-Cal
●	Streamlined administration of public insurance/ coverage programs for the underserved
Key Accomplishments and Milestones Achieved to Date:
●	Initiated a comprehensive approach for improving Enrollment, Eligibility and Retention (EER) of Medi-Cal through strategies that include training, use of information technology (particularly the One-e-App web-based health coverage enrollment tool), and changes in operational practices that focus on Medi-Cal and other federal and state public coverage programs.
●	Partnered with Human Services Agency to support the creation of a specialized Aged, Blind and Disabled (ABD) unit staffed by Benefit Analysts that will enable improved enrollment and retention of Medi-Cal among older adults and persons with disabilities. The unit was established in August 2008 so it is too early to assess the improvement in Medi-Cal retention among this client group.
●	Implemented an initiative to increase capture of Medi-Cal Minor Consent revenue at the Daly City Youth Health Center, with a plan to replicate at Sequoia Teen Wellness Center in the fall. The number of adolescents enrolled in Medi-Cal Minor Consent at DCYHC increased from 4 in April 2008 to 92 in August, 2008. The proportion of visits covered by Medi-Cal Minor Consent at DCYHC increased from 1.5% to 22% of total visits between April and August, 2008.
●	Developed an approach to unify training of front-line staff involved in health coverage enrollment across County entities (Health, Human Services Agency, San Mateo Medical Center) in alignment with the core competencies for all County staff developed by Human Resources.
●	Developed draft process and materials to improve client understanding of options available to assist them in obtaining WELL coverage due to financial hardship.
●	Developed a process to monitor eligibility for Medi-Cal pending accounts and recode the accounts to Medi-Cal once eligibility has been established. Between January 2008 and August 2008, 751 accounts totaling $484,263 were recoded to Medi-Cal.
●	Developed a proposal presented to the County Manager’s Office to transfer administration of the WELL program from the County to HPSM effective January 1, 2009. This action will continue movement toward a seamless and coordinated coverage program for the population with incomes below 200% of the Federal Poverty Level, in alignment with the recommendations of the BRTF.
Chronic Disease Management and Care Coordination
Overall Goals:
●	Identification and management of patients/members whose complex and/or combination of chronic disease(s) leads to inefficient/ inappropriate utilization of medical resources
●	Improved management of chronic disease across systems to ensure efficiency and effectiveness in care coordination and targeting of medical resources
Key Accomplishments and Milestones Achieved to Date:
●	Finalized plans to open the “Innovative Care Clinic” (which is designed around a “radically redesigned” model of clinical care embodying key principles of chronic disease management as well as critical access for patients who would otherwise not be able to utilize care appropriately) within the SMMC Main Campus Adult Primary Care Clinic. We are currently in the process of hiring staff and making minor facility improvements to accommodate them, and expect to begin full-scale operations by November 1, 2008.
●	Developed a complete inventory of Chronic Disease Management (CDM) efforts throughout the SMMC ambulatory system in an effort to better coordinate and advance efforts to promote CDM. Currently, every primary care site is enhancing efforts in this realm through some combination of patient visit redesign, group visits, improved patient self-management efforts, and chronic disease registry use, among other efforts.
●	Analyzed patient/ member statistics and identified target clients to improve assignment of clinical and other resources aimed at improving care and cost management. For example, in its first year, HOME team screened over 220 potential clients who had accessed the Emergency Room seven or more times during the prior year. As of June 1, 2008 the HOME team staff successfully enrolled 74 clients, with 64 active clients currently. After two quarters enrolled in the program (6-months), we see an overall decrease in ED use of 40% across HOME Team clients.
●	Improved data collection of key chronic disease management measures targeted by the Health Plan of San Mateo’s quality priorities, resulting in a total of $1.1 million in “Pay for Performance” funding captured by SMMC for fiscal year 2008-09.
●	Initiated workgroup to assess linkages and current efforts to address client health goals of Primary Care and Behavioral Health and Recovery Services to identify opportunities for strengthening medical care management of clients with mental health diagnoses.
●	Studied the health profiles of shared Behavioral Health and Recovery Services (BHRS)/ HPSM Care Advantage (CA) members and learned that these adults with mental illness have the health problems of members without mental illness who are 20+ years older, and that 44% of CA members have a dual diagnosis involving mental illness and a medical condition.
Integration Across Levels of Care
Overall Goals:
●	Increased proportion of clients being served in most appropriate level setting
●	Reduced proportion of clients who do not need acute care being served within an acute care setting
●	Improved access and integration across systems for long-term care planning and services
Key Accomplishments and Milestones Achieved to Date:
●	Designed and implemented a new “corner unit” resource within Burlingame Long-Term Care that provides improved support for clients with behavioral challenges and enables appropriate discharge of medical/surgical clients who do not need acute-level services. The medical/ surgical administrative day rate at SMMC has declined from a rate of 23% in January 2008 to an average of 8% between May through July 2008.
●	Analyzed needs and options for acute and lower-level psychiatric capacity and developed a plan to increase lower level capacity, on a phased basis in fiscal year 2009-2010 if expected system savings are achieved.
●	Negotiated a revised Memorandum of Understanding among SMMC, Behavioral Health and Recovery Services, Aging and Adult Services and the Health Plan of San Mateo that improves incentive alignment to maximize Medi-Cal enrollment and furthers BHRS programmatic initiatives aimed at strengthening co-occurring capacity across settings. In addition, initiated the development of a joint placement fund that will further improve resource coordination and incentive alignment in achieving placement for priority “hard-to-place” patients who do not require acute level care.
●	Clarified and trained all nursing staff on appropriate acute admission criteria and documentation practices to enable improved capture of Medi-Cal and Medicare reimbursement. The payer mix at Burlingame LTC improved from 4% Uninsured/Self Pay in Jan 2008 to 1% in both July and Aug 08. At, SMMC LTC, the proportion of Uninsured/Self-Pay decreased from 35% in Jan 2008 to 23% in Aug 2008.
●	Completed and submitted a business and operational plan for the Long-Term Supportive Services Project (LTSSP) to the State of California to facilitate increased local control of and accountability for Medi-Cal long-term care funding. Initiated discussions with the State to work toward a July 1, 2009 start date for key LTSSP components.
Physician Leadership, Relationships and Accountability
Overall Goals:
●	Increased alignment of physician leadership and accountability with the healthcare delivery system goals and priorities of SMMC, HPSM and HD
●	Improved access and outcomes for patients/members accessing medical care within the County system
●	Increased cost-effectiveness in SMMC physician arrangements
Key Accomplishments and Milestones Achieved to Date:
●	Created job description and appointed a Chief Medical Officer, with delineated responsibility for physician leadership and accountability distinct from other medical leadership functions in SMMC.
●	Developed updated inventory of all employed and contracted physicians to enable analysis and prioritization of opportunities for improved standardization and cost-effectiveness.
●	Determined benchmarks for specialty care access to set employment and contracting standards, expectations and decisions, as well as strategies pursued in developing the Community Health Network for the Underserved.
●	Awarded (from Kaiser Northern California Community Benefit) in partnership with Ravenswood Family Health Center, a planning grant to improve access to specialty care. Identified five specialties for priority focus: cardiology, endocrinology, orthopedic surgery, gastroenterology, and ophthalmology.
●	Negotiated renewal of 16 major provider contracts in alignment with regional compensation benchmarks and with predictable annual costs. These contracts include clear expectations and transparency regarding productivity, call coverage, and other parameters.
Community Health Network for the Underserved
Overall Goal:
●	Creation of a public-private healthcare delivery system for the medically underserved (Medi-Cal and uninsured) that includes defined roles for each major private sector hospital, major ambulatory care providers and a redefined role for SMMC/ the County
Key Accomplishments and Milestones Achieved to Date:
●	Completed a provider capacity analysis that built on analysis performed as part of the BRTF planning phase recommendations to create an outline, by service area, of provider capacity needed to address the needs of the underserved.
●	Developed Community Health Network for the Underserved (CHNU) background document that synthesizes results of provider capacity and other analyses that build on the work of the BRTF to articulate primary goals for the CHNU and the role that the County seeks to play (see Attachment 2).
●	Identified, from the deepened provider capacity analysis, targeted roles for each major provider organization that capitalizes on their specific strengths and complements the roles of others to achieve a sustainable distribution of delivery responsibilities across a public/private network.
●	Developed an initial proposal for expanded partnership that targets OB/Pediatrics, reshapes the County’s role within these two arenas, and will involve agreements with eight delivery system organizations.
●	As an initial step in executing a successful OB/Pediatrics partnership, achieved commitment from: • Kaiser Permanente and Permanente Medical Group to expand provision of OB and pediatric services in Redwood City, contracted by the Health Plan of San Mateo (360 deliveries and care for the newborns and siblings of those clients). • Lucile Packard Children’s Hospital (LPCH) to support physician capacity for deliveries at LPCH (600-700), as well as capacity building of County pediatric capacity (2.0 FTE pediatricians for FY 08-09 and assistance with capital support for expanded pediatric capacity in South County). • Mills Peninsula Health Services to evaluate increased hospital capacity for deliveries (200-300) provided to mothers covered by Medi-Cal living in Mid-County. • Palo Alto Medical Foundation to support OB physician capacity for deliveries (30 -100) to mothers covered by Medi-Cal living in Mid-County at Sequoia Hospital. • Ravenswood Family Health Center to continue its role in providing prenatal care (2,240 visits) for mothers covered by Medi-Cal living in the East Palo Alto and Belle Haven areas. • Sequoia Hospital to support increased hospital capacity for deliveries (30 -100) provided to mothers covered by Medi-Cal living in Mid-County. • Seton Medical Care Center to support increased hospital capacity for deliveries (100-200) provided to mothers covered by Medi-Cal living in North-County.
●	Worked in partnership with LPCH, Ravenswood Family Health Center and HPSM to complete an initial planning process to assess the medical needs of publicly covered children in San Mateo County, with a particular focus on South County, to identify opportunities and gaps in achieving a coordinated safety net approach.
●	Developed an initial proposal and achieved agreement for an expanded partnership with Kaiser Permanente and Permanente Medical Group to achieve more effective arrangements in provision of targeted surgical subspecialty services.
●	Developed an initial proposal and achieved agreement for an expanded partnership with Palo Alto Medical Foundation to achieve more effective arrangements in provision of targeted medical subspecialty services.
●	Developed an alignment of contracted facility and technical services with the HPSM Medi-Cal rate structure and achieved agreement from Mills Peninsula Health Services and Sequoia Hospital to implement this change.
●	Analyzed the most effective structure for clinical resources shared across SMMC and Public Health and Environmental Protection in the provision of infectious disease and AIDS medicine services and developed a jointly supervised supervising physician position for AIDS Medicine and Infectious Disease.
Long-Term Care
Overall Goal:
●	Improved County financial position in direct delivery of long-term care services
Key Accomplishments and Milestones Achieved to Date:
●	Through focused advocacy and follow-up on high priority cases, assisted seven clients at Burlingame Long Term Care Center in achieving retroactive Medi-Cal coverage/retaining current coverage, resulting in an estimated $1.2 million in increased Medi-Cal revenue to SMMC.
●	Hosted forum with HMA expert on long-term care business development to discuss potential opportunities and strategies to explore in San Mateo County.
●	Initiated exploration of opportunities for partnership with two delivery system partners seeking long-term care capacity and the role that SMMC could play in meeting that need through arrangements that support other aspects of SMMC’s mission.
Strategic and Operational Financial Improvement
Overall Goals:
●	Improved County financial position in delivering medical care
●	Improved finance capacity within SMMC to inform strategic health system decisions
Key Accomplishments and Milestones Achieved to Date:
●	Developed and implemented plan to improve billing and collections functions. SMMC cash collections/ month have increased from $6.4M in January 2008 to $8.3M in May 2008.
●	Developed plan for increased Medi-Cal Inter-Governmental Transfer (IGT) from the State to the County (via HPSM) to support SMMC operations. Negotiated with the State to achieve an increase of $4 million in revenues to SMMC for 08-09 with negotiations to continue regarding the potential additional positive impact achievable through HPSM’s LTSSP proposal.
●	Developed proposal and achieved a grant award of $1.6 million from the Sequoia Healthcare District to support the cost of healthcare for uninsured adults living within the Sequoia region and served by SMMC (i.e., the Fair Oaks Clinic and services referred to the Main Campus).
Next Steps
Informed by the Redesign process and the work of the BRTF, the BOS approved actions to create a unified Health System comprising the functions carried out by the Health Department and SMMC. A recruitment is underway for the role of Health System Chief, with the expectation that a hiring decision will be made by the end of 2008. The Redesign effort is adapting its structure under the leadership of Charlene A. Silva, Interim Chief of the Health System.
The Redesign leadership is planning briefings with the two healthcare districts (Peninsula and Sequoia) to discuss their potential roles in supporting the Community Health Network for the Underserved. Conversations begun through the BRTF planning, and the respective strategic planning processes of the two districts indicate both districts’ strong interest in contributing to initiatives that address priority health issues, such as access to healthcare for underserved adults. Both districts have been key partners in the countywide Children’s Health Initiative, which has created universal health insurance coverage for children in San Mateo County. The Sequoia Healthcare District has also invested in improved access to healthcare for uninsured adults through a grant awarded to SMMC to support care provided to District residents served by the Fair Oaks Clinic and services offered at the SMMC Main Campus. The Redesign team looks forward to the Board of Supervisors’ involvement in further conversations with District Board members.
The Redesign leadership is considering governance and management models for the CHNU. On October 16th, the Redesign leadership group convened private sector delivery system partners in the second meeting of physician, community health center, and hospital organizations committed to participation in the CHNU. A workgroup with representation of delivery system partners and Redesign leadership members will develop recommendations for governance and network management, with the guidance of County Counsel as appropriate regarding the County’s role and responsibilities. We will continue to keep you apprised of these discussions and bring forward any County policy decisions related to these issues.
The Redesign Team has implemented a contract with the Urban Institute (approved by the BOS on July 8, 2008) to evaluate key aspects of Redesign and its focus on improving access and coordination of care across the SMMC and Ravenswood Family Health Center (RFHC) safety net network, and improving the effectiveness of care for clients with chronic diseases. The evaluation team completed an initial site visit, involving 44 stakeholders during the week of August 11th and will be providing information on initial findings that will be incorporated in a planned March 2009 update to the BOS and BRTF. We will continue to post key updates on the website established to communicate key milestones. Questions about the initiative can be directed to Srija Srinivasan, 573.2095, or ssrinivasan@co.sanmateo.ca.us.