Manual care management processes and eight legacy systems contributed to Fallon Community Health Plan's inability to manage the quality and cost-effectiveness of care for its members. The deployment of one consolidated member-centric and service-oriented care management application helped to eliminate the eight care management systems and provide more-efficient, effective business flows and improved program management.

• Improving health outcomes and lowering medical and administrative costs are driving the need for more-robust care management solutions for health insurers.
• Integrated use, case and disease management processes with a strong and flexible rule-driven workflow that encompasses clinical rules are key requirements for care management success.
• Care management applications provide health insurers with the foundation technology to improve financial, clinical and patient outcomes.

• Document and finalize business requirements, workflows and processes prior to system selection. First think of the processes and relate them to system design.
• Execute exhaustive due diligence when accessing the care management vendor market. The vendor market is vast and includes legacy vendors with old technology and emerging vendors with service-oriented products.
• Develop a comprehensive training and user adoption plan, and engage case managers to meet user acceptance levels within appropriate time frames.

Fallon Community Health Plan (FCHP) is a 200,000-member healthcare services organization that supports its Commercial, Medicare Advantage, Managed Medicaid, Program of All-Inclusive Care for the Elderly and Commonwealth Care/Choice lines of business. FCHP faced a host of challenges with its current care management applications. The most important issue was that FCHP was using eight different systems for care management, all of which had inflexible technology and were unable to meet changing programs and market requirements, or support membership growth.

Care Coordination is the medical or clinical operational functions for Care Services at FCHP. Care Coordination consists of:

• Care Review for preauthorization of select medical outpatient and elective inpatient services
• Inpatient Care Services (IPCS) for all observation and nonelective inpatient acute, skilled nursing facilities, acute rehab and long-term acute care services
• Outpatient Care Services (OPCS) for complex case management and high-risk disease management (care management) programs.

The functions needed to support these services were handled by many stand-alone systems and manual and disconnected care management processes.

FCHP separated from Fallon Healthcare System and Fallon Clinic in 2003. At the time, FCHP began to develop and implement a more fully structured, organized and integrated (to itself and the business) Care Services division. The FCHP IPCS and OPCS case management teams used eight different care management systems to manage health plan members and care management programs. Only two of the eight systems interacted with the core claims/benefit system, benefit engine and the FCHP data warehouse. All of the systems were stand-alone, not integrated and built as "hard-coded." Therefore, they were not flexible enough to be updated as business needs changed. These systems were not supported by IT and required that the business support and fix the applications as they became older and increasingly dysfunctional.

In addition to the system challenges, FCHP was not using business resources wisely. Case managers — referred to as nurse care specialists (NCSs) — were used to perform additional manual system checks along with managing their heavy caseloads. FCHP found itself increasing the number of staff in order to manage the same or fewer numbers of care management programs and members enrolled in these programs.

The care management systems offered very little productivity, clinical and financial reporting. One of the systems provided no reports at all. This was due to the vast amount of customization made to a hard-coded application that was installed in 2003. The system was so highly customized that none of the standard reports worked. There was no routine reporting on process measures, productivity or outcomes. FCHP Care Coordination found it difficult to show utilization and/or health outcomes to external stakeholders (brokers/employers). There was a lack of ability to share timely and meaningful information to providers. FCHP's internal Microsoft Access databases did provide a limited number of process measures (such as number of members under management). However, FCHP was unable to produce outcome reports to track/show savings due to care management programs.

Multiple internal departments (business, IT, finance and sales) were affected by these deficiencies, which hampered FCHP's ability to scale with the business as they grew. The impact was so significant that, without the creation of a strategy to replace or improve the care management systems, FCHP faced serious ramifications, including:

• A potential accreditation problem for new 2007 standards for National Committee for Quality Assurance and all other government program requirements (Centers for Medicare & Medicaid Services [CMS], MassHealth and Commonwealth Connector)
• Loss of credibility with key provider groups
• Inability to meet reporting requirements called for in joint-funding agreements with select provider groups
• Potential loss of funding for the Diabetes Disease Care Services program because of the lack of workflow, automation and reporting capabilities
• Inability to change to meet accreditation, state and/or MassHealth or Medicare requirements, such as for Special Needs Programs
• Inability to expand program capacity to manage more members, or to add new programs or support new products
• Inability to support Part D Medication Therapy Management program

In 2006, FCHP had a window of opportunity to move to one care management application before two major events were to take place:

• A major corporate project to replace the core claims/benefit system was launching in October 2007.
• The contract for one of FCHP's major care management systems was ending in July 2008.

FCHP had to consider three options to determine the appropriate approach to its care management needs:

1. Do nothing and continue to maintain eight nonintegrated care management systems.
2. Keep adding case management staff to support increasing caseloads.
3. Seek an integrated care management application solution that would replace all eight care management systems.

Based on the extensive number of challenges with their current systems and the ramifications of not replacing these systems, FCHP decided to analyze the vendor market for a new care management application. FCHP created the following business objectives prior to the request-for-proposal (RFP) process:

• Consolidate multiple applications into one robust application and enhance the workflow, primarily in case management
• Automate current manual business tasks and processes
• Develop the ability to import and export data from the application
• Build the capability to store data in a warehouse
• Develop the ability to produce operational, management, clinical and financial outcomes reports

The vendor selection process started in May 2006. An RFP was sent out to 18 vendors in the healthcare insurer care management market. A full assessment was performed for a "potential" care management application. The final vendor was selected in January 2007.

Casenet was selected to be the case management vendor for the following reasons:

• It was flexible enough to be built to FCHP's current and future business processes.
• The system integrated with McKesson's InterQual product, which was already in place at FCHP.
• The system had the ability for case managers to work remote-connected and remote-disconnected.
• Casenet did the best job of building a demonstration system based on FCHP's business use-case scenarios and processes within a short time frame.

The implementation was broken into two phases: Phase 1 for OPCS and Phase 2 for IPCS. Phase 1 of the project was launched in March 2007 and went live in August 2007. Phase 2 of the project was launched in November 2007 and went live in late May 2008. The project objectives for Phase 1 included:

• Consolidate multiple OPCS applications into one robust application.
• Create more-efficient, automated workflows and processes for OPCS staff.
• Enable program reporting for OPCS.
• Support regulatory obligations (National Committee for Quality Assurance accreditation across three products, MassHealth and CMS regulations).
• Validate the vendor platform and flexible technology.

Phase 1 of the implementation was completed in 20 weeks. Few FCHP IT resources were used for this phase of the project. Casenet carried the heavy load of resources to make the implementation successful.

The results of the implementation of one consolidated system for OPCS were significant:

Operational efficiencies:

• Better coordination for member care was created across programs as well as departments.
• OPCS increased its average caseload from the low 70s to 85 to 90 cases per full-time equivalent (FTE) NCS.
• OPCS decreased staff to cover the same member panels and programs (eliminating 6.6 FTE NCSs, one FTE manager and one FTE business support position).
• OPCS/IT spent 25% less on service for systems maintenance post go-live.
• The outpatient population was handled more efficiently through more-efficient workflows and automation of manual care management tasks to support disease, utilization and case management.
• A decreased amount of time was needed to start or open a case with direct feed of member demographics, eligibility and benefit/plan information from the data warehouse.
• A decreased amount of time was needed to determine if a member was currently enrolled in an OPCS program.
• The ability for clinical staff to manage members throughout multiple levels of programs within one system or platform was increased.

System efficiencies:

• Platforms in Care Coordination were consolidated from eight systems to one.
• The system provided remote connected and disconnected functionality.
• The system eliminated a central member registry, a separate system (Microsoft Word) for OPCS welcome and program letters, and multiple semimanual access database and Excel spreadsheet tracking systems.
• The system improved compliance with regulatory requirements.

Reporting:

• The Casenet system is producing reports and will be able to "speak" to the new core administrative system (which is in implementation).
• Care was communicated better across programs as well as departments.
• Reporting is consolidated and improved through enhanced data capture.
• Data can now be stored in a warehouse.
• FCHP staff can produce department-, program-, member- and/or staff-based reports.
• FCHP staff can produce operational, management, clinical and financial outcomes reports.

• A full due diligence process ensured that FCHP knew what it needed in order to select the best possible vendor.
• A strong and engaged executive sponsor was crucial.
• Strong and engaged business leaders were subject-matter experts.
• The project plans allocated three months for user acceptance. Because the efforts to gain user acceptance were so successful, this was done in less than two months.
• All business workflows/processes were finalized and documented prior to system selection and specification.
• Case management staff went through full system training prior to go-live.
• Efforts were made to minimize the disruption of business functions during system transition; anticipated disruptions were scheduled to have minimal impact and be communicated to all parties.
• A strong partnership with the care management vendor was vital. Casenet provided extensive hands-on business analysis, IT and customer support for this implementation.

• Process documentation was limited because of work-around models previously set up to compensate for eight disconnected management applications. These work-around models could have been streamlined and documented prior to system selection.
• A better analysis of the care management vendor market could have been performed prior to the RFP process to prepare a shortlist of vendors. Managing the RFP process for 18 vendors was challenging and lengthy.
• Vendor responses to RFPs required validation during system overviews and demonstrations. In several instances, the vendor either misinterpreted or misread the question, and in so doing, either it did not reply to the question or the answer given was converse to the functionality of the system. As an example, at least four vendors that stated they could support connected/disconnected remote functionality failed during system demonstrations.