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DC Financial Responsibility and Management Assistance Authority
Health Services Reform Initiative
April 11, 2001

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Health Services Reform Initiative

Table of Contents

Legend
Introduction
Eligibility
Delivery System
Risk Protection
Implementation
HR Transition
Transition with Patient Scenarios
Conclusion

LEGEND

CH = CONGRESS HEIGHTS CLINIC
CHP = CHARTERED HEALTH PLAN (PRIMARY SUBCONTRACTOR)
CNMC = CHILDREN'S NATIONAL MEDICAL CENTER (PRIMARY SUBCONTRACTOR)
DCGH = DC GENERAL HOSPITAL
DOH = DEPARTMENT OF HEALTH
EMS = EMERGENCY MEDICAL SYSTEM
GSCH = GREATER SOUTHEAST COMMUNITY HOSPITAL (PRIME CONTRACTOR)
HR = HUMAN RESOURCES
NPCC = NON PROFIT CLINIC CONSORTIUM
OEEP = OUTREACH, ENGAGEMENT, EDUCATION, PREVENTION
PBC = PUBLIC BENEFIT CORPORATION
RIF = REDUCTION IN FORCE
UNITY = UNITY HEALTH CARE, A FEDERALLY QUALIFIED HEALTH CENTER FUNDED THROUGH THE FEDERAL 330 PROGRAM. (PRIMARY SUBCONTRACTOR]

INTRODUCTION

CURRENT ENVIRONMENT

ABYSMAL HEALTH STATISTIC INCLUDING:
- LOWER LIFE EXPECTANCY FOR AFRICAN AMERICAN MALES 10 YEARS LOWER THAN NATIONAL AVERAGE
- HIGHEST NATIONAL RATES OF HIV INFECTION
- HIGHEST NATIONAL RATES OF INFANT MORTALITY
- HIGHEST NATIONAL RATES OF DIABETES
LITTLE FOCUS ON PRIMARY CARE AND PREVENTION
LITTLE OR NO ACCOUNTABILITY FOR HEALTH SERVICES DELIVERY
ESCALATING/UNCONTROLLED COST OF PUBLIC SYSTEM
INABILITY TO IDENTIFY OR QUANTIFY UNINSURED

OUR APPROACH

REDESIGN HEALTH CARE DELIVERY SYSTEM
PLACE ACCOUNTABILITY AND RESPONSIBILITY FOR DRIVING HEALTH REFORM WITH THE DEPARTMENT OF HEALTH
ENCOURAGE PRIMARY CARE HOMES FOR EVERYONE ENROLLED IN THE PROGRAM
ENCOURAGE PUBLIC/PRIVATE PARTNERSHIPS INCLUDING NON-PROFIT COMMUNITY BASED PROVIDERS
MULTIFACETED INTERAGENCY HEALTH PROMOTION AND EDUCATION CAMPAIGN INCLUDING DCPS, RECREATION, LIBRARIES

OUR GOALS FOR HEALTH REFORM

BUILD A TRUE SAFETY NET
COMPREHENSIVE, INTEGRATED SYSTEM
EMPHASIS ON PRIMARY AND PREVENTIVE CARE
DATABASE OF PATIENT POPULATION AND UTILIZATION PATTERNS
AGGRESSIVE QUALITY MANAGEMENT PROGRAM FOR INCREASE ACCOUNTABILITY

ELIGIBILITY

ELIGIBILITY CRITERIA FOR DC ALLIANCE PROGRAM

DISTRICT OF COLUMBIA RESIDENTS WITHOUT HEALTH INSURANCE
FAMILY INCOME AT OR BELOW 200% OF THE FEDERAL POVERTY LEVEL
- FAMILY OF ONE — $17,180
- FAMILY OF TWO — $23,220

INELIGIBLE PATIENTS

DO NOT MEET RESIDENCY REQUIREMENTS
HAVE INCOME ABOVE 200% FEDERAL LEVEL
ARE COUNTED TOWARD MAINTENANCE OF EFFORT
REQUIRES COORDINATION WITH ARCHDIOCESAN HEALTH NETWORK TO DETERMINE LEVEL OF SPECIALTY AND ANCILLARY CARE PROVIDED THROUGH THEIR NETWORK

MAINTENANCE OF EFFORT

ALL PROVIDERS SUBJECT TO "MOE" REQUIREMENTS
HOSPITALS "MOE" DETERMINED BY DOLLARS
ALL OTHER PROVIDERS "MOE" DETERMINED BY VOLUME OF SERVICES PROVIDED
INDIVIDUALS SEEN AT CLINICS MAY BE INELIGIBLE FOR PRIMARY CARE SERVICES, BUT ELIGIBLE FOR ALL OTHER BENEFITS THROUGH THE PROGRAM

DELIVERY SYSTEM

SERVICES OFFERED

INPATIENT SERVICES AT CONTRACTOR HOSPITAL
OUTPATIENT AND SPECIALTY SERVICES STAY AT DC GENERAL HEALTH CAMPUS, COMMUNITY BASED HEALTH CENTERS, AND CONTRACTOR FACILITY
FULL SERVICE 24-HOUR EMERGENCY DEPARTMENT REMAINS AT DC GENERAL HEALTH CAMPUS
TRAUMA CARE FOR THE MOST SERIOUS TRAUMA AT CONTRACTOR SITE AND OTHER FACILITIES
PRIMARY CARE THROUGH MORE THAN 100 PROVIDER LOCATIONS
DISEASE MANAGEMENT
DENTAL CARE
PHARMACY
INCREASE OF UP TO 34% IN AMOUNT OF SERVICES PROVIDED
COMPREHENSIVE INFORMATION SYSTEM TO COORDINATE CARE AND GATHER PATIENT SPECIFIC AND AGGREGATE DATA

RISK PROTECTION

SHARED REWARD AND RISK
ENHANCED ABILITY TO MANAGE RISK THROUGH:
- CONTRACTS TO MONITOR COSTS, QUALITY AND UTILIZATION
- QUARTERLY RECONCILIATIONS
- ABILITY TO ADJUST RATES AND UTILIZATION PROJECTIONS
- ACCURATE DATA
SEGREGATED ACCOUNT
ESCROW TYPE ARRANGEMENT
PERFORMANCE BOND
REINVEST IN SAFETY NET

IMPLEMENTATION

IMPLEMENTATION PHASE

ESTABLISH IMPLEMENTATION TEAM LEAD BY DOH, PBC AND CONTRACTOR

[Flow chart 1]

CONDUCT REGULAR MEETINGS OF IMPLEMENTATION TEAM
COMMUNITY INVOLVEMENT/INPUT
TRACK PROGRESS OF IMPLEMENTATION TO ASSURE READINESS FOR OPERATIONS
REGULAR PROGRESS REPORTS TO EOM, COUNCIL, DCFRA, AND COMMUNITY
CONFIRM ROLL OUT DATES

IMPLEMENTATION PHASE DOH

DEVELOP DOH OPERATIONAL CAPACITY
MONITOR TRANSITION FINANCIAL PLAN
PROVIDE TECHNICAL ASSISTANCE TO COMMUNITY BASED PROVIDERS
CONDUCT READINESS REVIEW
IMPLEMENT COMMUNICATIONS PLAN MODELED AFTER OEEP (OUTREACH, ENGAGEMENT, EDUCATION AND PREVENTION)
MONITOR EMS READINESS
NEW LEGISLATION

DOH OVERSIGHT STRUCTURE

[Flow chart 2]

IMPLEMENTATION PHASE PBC

MAINTAIN HOSPITAL/CLINIC OPERATIONS THROUGH TRANSITION
IMPLEMENT HR PLAN
IMPLEMENT COMMUNICATIONS PLAN
BEGIN STAKEHOLDER NOTIFICATION PROCESS
FINALIZE RESIDENT TRANSFERS
PREPARE DATA TRANSFER
PARTICIPATE IN READINESS REVIEW
PREPARE HOSPITAL FOR TRANSITION

IMPLEMENTATION PHASE GSECH AND SUBS

OVERSEE RENOVATION PROJECTS AT DC GENERAL CAMPUS, CLINICS, GSCH
ANALYSIS OF COMMUNITY BASED HEALTH CENTERS
DEVELOP INFORMATION TECHNOLOGY CAPACITY FOR COMMUNITY BASED PROVIDERS
RECRUIT AND HIRE STAFF
CREDENTIAL PROVIDERS
MANAGE DATA TRANSFER AND DEVELOP INITIAL DATABASE OF USERS
BEGIN INITIAL ENROLLMENT OF USERS
DEVELOP AND IMPLEMENT OUTREACH AND EDUCATION STRATEGY
DEVELOP REPORTING AND COMPLIANCE CAPABILITY
PREPARE GSECH FOR TRANSITION

HR TRANSITION

DEPARTMENT OF EMPLOYMENT SERVICES COMMITMENT:
- PROVIDE RIF INFORMATION SEMINARS
- CONDUCT QUALIFICATIONS ANALYSIS
- IMPLEMENT DISLOCATED WORKER PROGRAM
- OPERATE EMPLOYEE RESOURCE ROOM WITH INFORMATION ON UNEMPLOYMENT COMPENSATION, JOB SEARCH/CAREER TRANSITION
- RETRAIN/UPGRADE SKILLS
- PROVIDE COMPUTER TRAINING
- IDENTIFY CURRENT AND FUTURE JOB OPENINGS WITH EMPLOYERS THROUGH THE METROPOLITAN AREA
- JOB FAIRS
FOR MOST EMPLOYEES RIF WOULD OCCUR OVER 60-90 DAYS
DISCUSSIONS WITH DCOP REGARDING EARLY OUT FOR ELIGIBLE DCGH EMPLOYEES
POTENTIAL INCENTIVES TO ENCOURAGE KEY STAFF TO REMAIN THROUGH TRANSITION
PROVIDE EMPLOYEES WITH OPPORTUNITY TO VERIFY/UPDATE SERVICE DATA
PROVIDE EMPLOYEE ENTITLEMENT COUNSELING
ESTABLISH CONTACT WITH EAP TO HAVE COUNSELING AVAILABLE TO DISPLACED EMPLOYEES AS DESIRED

TRANSITION WITH PATIENT SCENARIOS

TRANSITION — MONTH ONE

INFORMATION TECHNOLOGY IMPLEMENTATION
PROVIDER CONTRACTING AND CREDENTIALING
IMPLEMENT COMMUNITY COMMUNICATIONS STRATEGY (OEEP)
CLINIC ANALYSIS
COMPLETE EMS RESTRUCTURING
INITIATE HR STRATEGY

PATIENT SCENARIOS FOR TRANSITION MONTH 1

INPATIENT MONTH ONE

54 YEAR OLD CONFIRMED DIABETIC ARRIVES AT DC GENERAL ER COMPLAINING OF NOT FEELING WELL
HISTORY TAKEN DISCOVERS PATIENT WITHOUT INSULIN FOR 2 MONTHS
BLOOD SUGAR DRAWN DISCOVERED TO BE OVER 500
PATIENT ADMITTED INTO DC GENERAL HOSPITAL
IN PATIENT MEETS ENROLLMENT CRITERIA ENROLL INTO PROGRAM

OUTPATIENT MONTH ONE

29 YEAR OLD MALE ARRIVES AT UNITY OR NPCC. DIAGNOSED WITH BROKEN FOOT AND REFERRED FOR FOLLOW-UP CARE TO DCGH
PATIENT SEEN IN ORTHOPEDIC CLINIC ON SITE AT DC GENERAL HEALTH CAMPUS
IF ELIGIBLE, ENROLLED IN PROGRAM

OUTPATIENT COMMUNITY CLINIC (FORMER-PBC) MONTH ONE

PATIENT NORMALLY SEEN AT CH CLINIC NOT FEELING WELL
DECIDES TO GO TO CLINIC
CALLS FOR APPOINTMENT OR WALKS IN TO CLINIC
SEEN IN CH CLINIC, TREATED AND DISCHARGED HOME
IF ELIGIBLE, ENROLL IN PROGRAM

UNITY OR NPCC BASED MONTH ONE

PATIENT ARRIVES AT UNITY OR OTHER NON PROFIT CLINIC SITE COMPLAINING OF HEADACHE AND DIZZINESS WITH VOMITING FOR 2 DAYS
PHYSICIAN EXAMINES PATIENT AND DECIDES THAT PATIENT NEEDS ADMISSION
PATIENT REFERRED FOR ADMISSION TO DCGH
IF ELIGIBLE, ENROLL IN PROGRAM

TRAUMA MONTH ONE

EMS RESPONDS TO SCENE OF AUTOMOBILE ACCIDENT IN WARD 6
EMS DOES ASSESSMENT AND DETERMINES THAT INDIVIDUAL NEEDS TRAUMA 1 LEVEL OF CARE
EMS TAKES VICTIM TO NEAREST LOCATION THAT PROVIDES TRAUMA 1 LEVEL OF CARE

TRANSITION — MONTH 2

AFTER SUCCESSFUL READINESS REVIEW CONTRACTOR ASSUMES RESPONSIBILITY FOR ALL CARE
CHARTERED BEGINS MANAGEMENT FUNCTIONS (ENROLLMENT, CONTRACTING, CLAIMS PROCESSING ETC.)
INPATIENT CARE PROVIDED AT CONTRACTOR SITE (25 BEDS AVAILABLE AT GSCH) AND DC GENERAL HEALTH CAMPUS
AMBULATORY CARE CONTINUES AT COMMUNITY SITES AND DC GENERAL HEALTH CAMPUS
25 BEDS AT DCGH TRANSITIONED AS APPROPRIATE

PATIENT SCENARIOS FOR TRANSITION MONTH TWO

INPATIENT MONTH TWO

54 YEAR OLD CONFIRMED DIABETIC IN DCGH ER
HISTORY TAKEN DISCOVERS PATIENT WITHOUT INSULIN FOR 2 MONTHS
BLOOD SUGAR DRAWN DISCOVERED TO BE OVER 500
PATIENT TRANSFERRED TO CONTRACTOR HOSPITAL OR DCGH BASED ON BED AVAILABILITY
IF ADMITTED TO DCGH, CONTRACTOR REIMBURSES DISTRICT FOR CARE OF PATIENT
IF ELIGIBLE, ENROLL IN PROGRAM

OUTPATIENT MONTH TWO

29 YEAR OLD MALE ARRIVES AT UNITY OR NPCC. DIAGNOSED WITH BROKEN FOOT. REFERRED TO DC GENERAL HEALTH CAMPUS FOR FOLLOW UP CARE.
PATIENT SEEN IN ORTHOPEDIC CLINIC ON SITE AT DCGH
IF ELIGIBLE, ENROLL IN PROGRAM

OUTPATIENT COMMUNITY (FORMER-PBC) CLINIC MONTH TWO

PATIENT NORMALLY SEEN AT CH CLINIC NOT FEELING WELL
DECIDES TO GO TO CLINIC (PATIENT MAY CHOOSE ANY CLINIC OR PROVIDER IN THE SYSTEM)
CALLS FOR APPOINTMENT OR WALKS IN
SEEN IN CH CLINIC, TREATED AND DISCHARGED HOME WITH PRIMARY CARE FOLLOW-UP APPOINTMENT
IF ELIGIBLE, ENROLL IN PROGRAM

UNITY OR NPCC SCENARIO MONTH TWO

PATIENT ARRIVES AT UNITY OR OTHER NON PROFIT CLINIC SITE COMPLAINING OF HEADACHE AND DIZZINESS WITH VOMITING FOR 2 DAYS
PHYSICIAN EXAMINES PATIENT AND DECIDES THAT PATIENT NEEDS ADMISSION
PATIENT ADMITTED TO GSECH OR DCGH BASED ON BED AVAILABILITY
IF ADMITTED TO DCGH, CONTRACTOR REIMBURSES DISTRICT
IF ELIGIBLE, ENROLL IN PROGRAM

TRAUMA MONTH TWO

EMS RESPONDS TO SCENE OF AUTOMOBILE ACCIDENT IN WARD 6
EMS DOES ASSESSMENT AND DETERMINES THAT INDIVIDUAL NEEDS TRAUMA 1 LEVEL OF CARE
EMS TAKES VICTIM TO NEAREST LOCATION THAT PROVIDES TRAUMA 1 LEVEL OF CARE

TRANSITION — MONTH 3

RENOVATIONS COMPLETE AT ALL SITES
TRAUMA CAPABILITY CONSISTENT WITH DCGH CAPABILITY IMPLEMENTED
IF READINESS REVIEW SUCCESSFUL DISCONTINUE ADMISSIONS TO DCGH
COMPLETE MED SURG TRANSITION
TRANSITION CORRECTIONAL MEDICINE
CONTINUE TRANSITIONAL HOSPITAL FUNCTIONS

PATIENT SCENARIOS FOR TRANSITION MONTH 3

INPATIENT MONTH THREE

54 YEAR OLD CONFIRMED DIABETIC AT DCGH ER
HISTORY TAKEN DISCOVERS PATIENT WITHOUT INSULIN FOR 2 MONTHS
BLOOD SUGAR DRAWN DISCOVERED TO BE OVER 500
PATIENT TRANSFERRED TO CONTRACTOR HOSPITAL FOR ADMISSION
IF ELIGIBLE, ENROLL IN PROGRAM

OUTPATIENT MONTH THREE

29 YEAR OLD MALE ARRIVES AT UNITY OR NPCC. DIAGNOSED WITH BROKEN FOOT. REFERRED TO DC GENERAL HEALTH CAMPUS FOR FOLLOW UP CARE.
PATIENT SEEN IN ORTHOPEDIC CLINIC ON SITE AT DCGH
IF ELIGIBLE, ENROLL IN PROGRAM

OUTPATIENT COMMUNITY (FORMER-PBC) CLINIC MONTH THREE

PATIENT NORMALLY SEEN AT CH CLINIC NOT FEELING WELL
DECIDES TO GO TO CLINIC (PATIENT MAY CHOOSE ANY CLINIC OR PROVIDER IN THE SYSTEM)
CALLS FOR APPOINTMENT OR WALKS IN
SEEN IN CH CLINIC, TREATED AND DISCHARGED HOME WITH PRIMARY CARE FOLLOW-UP APPOINTMENT
IF ELIGIBLE, ENROLL IN PROGRAM

UNITY OR NPCC MONTH THREE

PATIENT ARRIVES AT UNITY OR OTHER NON PROFIT CLINIC SITE COMPLAINING OF HEADACHE AND DIZZINESS WITH VOMITING FOR 2 DAYS
PHYSICIAN EXAMINES PATIENT AND DECIDES THAT PATIENT NEEDS ADMISSION
PATIENT ADMITTED TO GSECH
IF ELIGIBLE, ENROLL IN PROGRAM

TRAUMA MONTH THREE

EMS RESPONDS TO SCENE OF AUTOMOBILE ACCIDENT IN WARD 6
EMS DOES ASSESSMENT AND DETERMINES THAT INDIVIDUAL NEEDS TRAUMA 1 LEVEL OF CARE
EMS TAKES VICTIM TO NEAREST LOCATION THAT PROVIDES TRAUMA 1 LEVEL OF CARE

HOSPITAL INPATIENT FUNCTIONS TRANSITION

ALL INPATIENT UNITS AND MOST SUPPORT SERVICES TRANSITIONED OVER 30-90 DAYS
MINIMAL STAFF RETAINED TO ASSIST WITH HOSPITAL TRANSITION
PATIENT BILLING AND COLLECTIONS CONTINUES UNDER CFO DIRECTION
INFORMATION SYSTEMS SUPPORT CONTINUES
HR FUNCTION MAINTAINED UNTIL ALL SYSTEMS AND UNITS TRANSITIONED

CONCLUSION

THE END RESULT

ENHANCED PRIMARY AND PREVENTIVE CARE LEADING TO IMPROVED HEALTH STATUS
INCREASED CAPACITY AND IMPROVED ACCESS TO CARE
COMPREHENSIVE HEALTH INFORMATION ON THE UNINSURED AND UTILIZATION PATTERNS ENHANCING ABILITY TO PREDICT COST
DECREASED HOSPITILIZATION AND INAPPROPRIATE EMERGENCY ROOM USE
ABILITY TO REINSURE UNINSURED POPULATION AND FURTHER MINIMIZE DISTRICT'S RISK
EXPANDED INSURANCE COVERAGE

DC Financial Responsibility and Management Assistance Authority Health Services Reform Initiative April 11, 2001