CM
Manage Population Health Outreach
Case Management
Description
The Manage Population Health Outreach business process is responsible for the implementation of strategy to improve general population health. The State Medicaid Agency (SMA) identifies target populations or individuals for selection by cultural, diagnostic, or other demographic indicators. The inputs to this business process are census, vital statistics, immigration, and other information sources. This business process outputs materials for: • Campaigns to enroll new members in existing health plan or health benefit. • New health plan or health benefit offering. • Modification to existing health plan or health benefit offering. It includes production of information materials and communications to impacted members, providers, and contractors (e.g., program strategies and materials, etc.). The communication of information includes a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI).
Business Process Template
Trigger events
Environment-based
- Receive information from census, vital statistics, public health departments, immigration, and other information sources.
- Periodic timetable (e.g., monthly, quarterly) to distribute information is due.
- Receive new population or problem-specific legislated health improvement initiatives.
- Receive request for information from other originators (e.g., federal actions or constituency interests).
Interaction-based
- Receive alert from Establish Case to place member into care management monitoring.
Results
- The SMA produces outreach communications (e.g., mailing brochures, web pages, email, kiosk, and radio, billboard, and TV advertisements) and distributes to targeted populations or individuals. The SMA may also conduct face-to-face meetings.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive request for outreach materials or communication.
- 2. Target population identified and defined by analyzing information, performance measures, feedback from community, and policy directives.
- 3. Approve, deny, or modify decisions to develop outreach communications.
- 4. Determine content and method of communication (e.g., email, mail, publication, mobile device, facsimile, telephone, web or EDI).
- 5. Determine performance measures.
- 6. Prepare content that is linguistically, culturally, and competency appropriate for the communication in agreed upon format.
- 7. Review and approve communication.
- 8. Generate communication in agreed upon format.
- 9. Agency logs communication message sent to target population.
- 10. END: Evaluate the efficacy of the communication (e.g., customer satisfaction, first time resolution rate).
Predecessor processes
- There are several business processes that can result in the interest or need to reach out to the Medicaid population in an attempt to improve behavior or promote prevention:
- Identify Utilization Anomalies
- Manage Performance Measures
- Manage Member Grievance and Appeal
- Manage Provider Grievance and Appeal
- Manage Health Plan Information
Successor processes
- Manage Applicant and Member Communication
- Perform Population and Member Outreach
- Manage Provider Communication
- Perform Provider Outreach
- Manage Contractor Communication
- Manage Performance Measures
Shared data
- Member data store including demographic information
- Provider data store including provider network Information
- Contractor data store including provider network Information
- Plan data store including policy information
- Health Benefit data store including program and service information
- Data from external agencies including: census, vital statistics, immigration, and various health registries
Constraints
Agencies do not coordinate amongst each other in order to share information. Potential political and inter-agency conflicts over appropriate use of health care information.
Failures
- Inter-agency agency communication or lack of access to information impairs ability to gather information to support strategies.
Performance measures
- Time to complete communication: By phone __ minutes; by email __hours; by mail __ days
- Accuracy of communications = __%
- Communications successfully delivered = __%
Source: CMS MITA 3.0 Business Process Template, Care Management BPT.pdf, pages 7-9.
Business Capability Model (10 questions)
Each capability question defines five maturity levels, from Level 1 through Level 5.
Business Capability Descriptions
Is the process primarily manual or automatic?
- LEVEL 1The process consists primarily of manual activity to accomplish tasks.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish process tasks. SMA complies information with a mix of manually and automatic reports.
- LEVEL 3SMA automates process to the full extent possible within the intrastate. SMA automates the identification of the target population to enhance case management services. SMA automates the matching of individuals with programs and materials to meet their needs.
- LEVEL 4SMA fully automates the process regionally to the extent possible across the interstate.
- LEVEL 5SMA fully automates the process nationally to the extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
- LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of outreach information.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and regional exchange of outreach information.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of outreach information.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
- LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions. SMA accesses a variety of information systems for research and reporting to identify members receiving medical care from multiple agencies simultaneously.
- LEVEL 3SMA collaborates with other intrastate agencies, and entities and the Regional Health Information Organization (RHIO) to adopt national standards, and to develop and share reusable business services.
- LEVEL 4SMA collaborates with other regional agencies, and entities, and the RHIO to adopt national standards, and to develop and share reusable processes including clinical information shared via a regional Health Information Exchange (HIE).
- LEVEL 5SMA collaborates with national agencies, and entities, and the RHIO for national (and international) interoperability improvements that maximize automation of routine operations shared across the Nationwide Health Information Network (NwHIN).
Business Capability Quality: Timeliness of Process
How timely is this end-to-end process?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
- LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
- LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
- LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has regional interoperability, which further improves timeliness over Level 3.
- LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.
Business Capability Quality: Data Access and Accuracy
How accurate is the information in the process?
- LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
- LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
- LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 90% or higher.
- LEVEL 4Automation of information collection increases the reliability of the regional SMA’s internal and external sources of information. SMA adopts MITA Framework for information exchange by regional agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy is 90% or higher.
- LEVEL 5SMA adopts MITA Framework for national information exchange. Decision-making is automatic using national standardized business rules definitions. Accuracy is 90% or higher.
How accessible is the information in the process?
- LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
- LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is, on average, no more than three (3) seconds.
- LEVEL 4SMA easily obtains and uses information from regional agencies and entities. Accessibility is, on average, no more than three (3) seconds.
- LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is, on average, no more than three (3) seconds.
Business Capability Quality: Cost Effectiveness
What is the cost to perform the process compared to the benefits of the results?
- LEVEL 1High relative cost due to low number of automatic, standardized tasks. The process operates within state budget constraints. The benefits vary depending upon the types of studies undertaken, the population studied, and the outcome of the research and/or findings.
- LEVEL 2Automation improves process and allows focus on exception resolution. The use of automation increases efficiency that allows additional benefits by focusing on increases reporting, more effective outreach, more directed outcomes, and automatic analysis. SMA increases the cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards. SMA is able to measure the usefulness of the types of studies undertaken, the population studied, and the outcome of the research and/or findings versus the cost of performing the process. SMA increases the cost effectiveness over Level 2.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for regional information exchange improving cost effectiveness ratio over Level 3.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process?
- LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving efficiency to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process?
- LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
- LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 99% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving accuracy to 99% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 99% or higher.
Business Capability Quality: Utility or Value to Stakeholders
Does the business process satisfy stakeholders?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving stakeholder satisfaction to 95% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.
Source: CMS MITA 3.0 Business Capability Model, Care Management BCM.pdf, pages 15-21.