The St. Louis Regional Health Commission's report Recommendations for Improving the Delivery of Safety Net Primary and Specialty Care Services recommended in October 2013 that current safety net providers form a permanent regional network to coordinate and integrate care to the medically underserved. This was followed by a federal grant from the Health Resources and Services Administration (HRSA) supporting the creation of such a network. And so, in November 2003, administrators from the area’s largest outpatient safety net providers gathered at the first organizational meeting of the St. Louis Integrated Health Network (IHN).
The IHN is designated by HRSA as a Health Center Controlled Network (HCCN), which is defined as a group of safety net providers collaborating horizontally and vertically to improve access to care, enhance quality of care, and achieve cost efficiency through the redesign of practices to integrate services and optimize patient outcomes. There are over 100 such networks nationwide, and the Missouri Primary Care Association also holds this designation.
Starting in 2004, workgroups were established by the IHN to plan for increased coordination and integration of safety net services. The impact has been significant. Here is a history of process improvement and care coordination efforts facilitated by the IHN:
• Joint Purchasing Committee (2004 to 2005) - Comprised of Chief Financial Officers for health centers and medical school designees, the Committee explored opportunities for working with a group purchasing organization for materials (medical/surgical supplies, office supplies, and other non-pharmaceutical purchase categories) and pharmaceuticals purchasing. Based on these efforts, individual health centers were able to re-negotiate directly with their vendors to establish a lower cost for materials purchases.
• Credentialing Workgroup (2004) – Working with Managed Medicaid plans to expedite billing processes for new providers, the workgroup helped health centers to reduce new provider billing wait time by two months. In addition, the Workgroup developed standard criteria for credentialing policies and procedures, meeting NCQA standards, which individual health centers implemented.
• Specialty Care Referral Task Force (2004 to 2007) - Created to reduce referral wait time for specialty care services uniquely provided by one member organization, the process improvement efforts of this Task Force resulted in reducing specialty care wait times from several months to within 14 days for most subspecialties during this timeframe.
• Breast Cancer Referral Initiative (2008 to 2009) - Designed to standardize and expedite the process of screening and referral of low income women with breast health issues, this Initiative promoted rapid treatment, diagnosis, and follow-up care. The results were reduced wait times for referral and treatment of breast abnormalities and increased communication and coordination of care for the most vulnerable population of women in the safety-net.
• Health Center Hospital Referral Task Force (2009 to 2010) - Comprised of health center and hospital care providers, the Task Force was created to identify and remove barriers faced by patients in order to obtain coordinated care across the safety-net system. The Task Force generated recommendations addressing both organizational and systemic changes to promote utilization of quality, accessible primary care and to reduce non-emergent use of hospital emergency departments
• Community Referral Coordination (CRC) Task Force (2010 to 2012) - Charged with implementing program improvements and tracking the follow-up of recommended system improvements, in addition to CRC program oversight, the outcomes of this Task Force’s work include establishing discharge protocols and methodology for retrieving data to prove program impact and examining transitions of care (TOC) efforts across the region. During the time frame of this task force’s oversight, the program expanded to seven sites and into the inpatient units of three hospitals. As a result of Task Force efforts, hospitals opened access to their electronic medical records for the CRC staff, and the CRC program gained national recognition due to an evaluation by the National Opinion Research Company (NORC)and widespread coverage of the program in a Commonwealth Foundation funded story. The CRC Task Force elected to transition its scope to include regional transitions of care and later became the TOC Collaborative.
• Marketing Committee (2010 to 2012) - Comprised of all marketing/public relations leaders in the Network, this Committee provided oversight to implement the IHN’s Marketing and Advocacy strategic priorities. Outcomes of the Committee’s work include the creation and dissemination of health care navigation resources, collaboration with local media outlets, and the development of “P.U.L.S.E,” an educational tool that represents the continuum of care including primary, urgent, lifestyle services (preventative), specialty, and emergency care. These efforts lead to the St. Louis American Foundation selecting the IHN as the “Advocacy Organization of the Year 2012.”
• Transitions of Care (TOC) Collaborative (2013 to present) - Formerly the CRC Task Force, this group consisting of hospitals, community health centers, and other stakeholders created a unified goal to promote and sustain high-quality, efficient patient transitions between hospitals (inpatient or emergency room) and the outpatient setting (primary care or urgently needed specialty care) through improved communication and coordination across health care organizations and with patients. The Collaborative established regional standards of care for TOC efforts and provides ongoing oversight, evaluation, and improvement of both the CRC Program and transitions of care across the region. The overall goal of this group is to join the silos of current TOC initiatives across the region. The CRC program transitioned from a grant-based program to a contracted sustainable service under the guidance of this Collaborative in 2014. Focusing on process improvement from both the systemic and programmatic perspectives, this group spearheaded changes being piloted within a partner hospital’s electronic medical record (EMR) system to allow CRC staff to change the Primary Care Provider name as needed and provided web access to charts for the Community Health Centers. In 2014, the Collaborative aims to further improve both transitions of care and EMR meaningful use metrics by working with area hospitals to exchange CCD/CCR (continuity of care document/record) data via direct electronic transmission through a health information exchange.
• Regional Health Information Technology Projects (2008 to present) – The IHN recognizes the need for coordinated electronic health information across IHN member organizations. In its most recent efforts, the IHN, Missouri Primary Care Association, and a technology vendor are working together to build and expand data elements ranging from insurance information to clinical indicators warehoused by the Missouri Primary Care Association. This data repository has been valuable for quality, processing improvement and reporting initiatives that benefit the patients receiving care within the St. Louis region’s safety-net.
• Pediatric Referral Task Force (2012 to 2013) - Formed in conjunction with the expansion of the CRC program to pediatric hospitals in 2011, this Task Force, representing both hospital and health center clinicians, was charged to provide oversight to the successful implementation of the CRC program into pediatric facilities and to make recommendations to improve care coordination efforts for the pediatric population. This group prioritized the transition of children who were at risk for or diagnosed with asthma as a target population, developing key protocols and procedures for assuring quick and informed access to the treatment, management, and tools this population needed. The Task Force also assisted with the development of pediatric-focused informational and marketing material to aid parents and children in understanding the importance of primary care.
• Network Branding and Health Education Committee (2014) - An extension of the original Marketing Committee, this Committee is charged with developing innovative strategies to advance the collective brand of quality affordable healthcare provided through the IHN. The Committee is also responsible for promoting increased health insurance literacy, as community members begin to purchase coverage through the Health Insurance Marketplace.