County Agencies Encounter Resistance to Forming an Integrated Family Health Maintenance Organization
During 1994 and 1995, staff at the Contra Costa County Department of Health Services sought to complete a plan to develop an enriched HMO program for families residing in the California county, with a particular focus on low income families served by the publicly-funded health services system.
However, the program, called the Family Maintenance Organization (FMO), did not come to fruition, chiefly due to the difficulties inherent in establishing linkages between agencies with different funding structures and the loss of key leadership during the planning phase.
- The basic outlines of the FMO Program were defined by late 1995. Two FMO service components were designed to change the health care utilization practices of low-income families:
- Integrating several categorical public health and maternal and child health programs into a parent education, outreach and support unit for the Bay Point community.
- Combining case management resources with substance abuse and mental health staff to establish a "behavioral health unit" that would provide more personal intensive teaching and support to families that are high utilizers of medical services or users of multiple health and human service programs.
- Largely due to the work on the FMO project, all county programs adopted the same broad family health outcome objectives.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $216,449.
Contra Costa County, located east of Oakland/Berkeley in the San Francisco Bay area, is a racially and economically diverse area with pockets of severe poverty. The Department of Health Services (DHS) has responsibility for basic health care, public health, mental health, and substance abuse. It also owns and operates its own mixed-income HMO with (at the time of the Family Maintenance Organization (FMO) planning) more than 5,000 families enrolled, of which 1,500 are county employees or members from other commercial accounts and the other 3,500 are families enrolled in the Medicaid program, called MediCal in California.
High-need families have extensive interaction with various agencies within the department, as well as other county agencies outside the department. Recognizing that the divisions in government services were neither family friendly nor fiscally efficient, the DHS had already taken some steps toward merging caseloads and developing integrated plans by creating an Office for Service Integration.
However, the county needs assessments of families also indicated a great need for social support, and the DHS's experience with blending services had shown that categorical financing and traditional service divisions were hampering, rather than enhancing, an integrated approach.
The concept of the Family Maintenance Organization (FMO), a new structure based on HMO principles, emerged as both a way to address the internal issues creating barriers to care and to provide family members with the skills, information, and support they needed to care for each other. The FMO concept grew out of a meeting of the county's Youth Services Board (YSB) a group comprised of the department heads for all child and family-serving agencies which subsequently initiated interagency Service Integration Teams in several of the county's poorest areas.
These teams combined the services of public health nurses, substance abuse counselors, mental health staff, probation officers, child protective services, and welfare workers, while merging caseloads and developing integrated plans with area families. The YSB enthusiastically endorsed the FMO proposal as a way of merging health and social care in a fiscally integrated program. The county Board of Supervisors also supported the project.
The goal of this project was to complete a design for an FMO for the county that would manage a range of medical, substance abuse, mental health, public health, and family support services under the aegis of the county DHS. The FMO would include services funded by other county agencies, such as social services, employment and training, child protective services, and the court system. The plan for the FMO would not only integrate services but also develop capitated financing for enrolled families.
The planning for the FMO was guided by two goals:
- to improve the health status of families;
- to create a health delivery system that included a focus on prevention and early intervention, was flexible enough to serve a variety of families with a range of needs, and was functionally and fiscally integrated.
DHS conducted information-gathering and analysis as part of its planning for the FMO, including:
- A "Family Needs and Strengths Assessment Report." A review of published materials and local reports defining family needs and strengths, along with interviews of local program managers and diverse family health experts. The report summarized the following key policy directions for the project:
- family-focused health solutions must grapple with the non-health system determinants affecting families, such as poverty and unemployment;
- a strength-based approach to families should be recognized and encouraged;
- social support is critical for families experiencing stress of various kinds;
- helping parents to provide stable environments for children and to negotiate stressful times is important;
- the dismantling of access barriers is primary to improving families' health;
- the fragmentation between medical care providers and programs/providers addressing social issues frustrates providers and families alike.
- There were 15 focus groups conducted with 141 parents or other guardians of various ethnic, racial, educational, and socioeconomic backgrounds. Staff learned that parents chiefly wanted access to timely, accurate information and support; they considered the manner in which services are provided to be just as important the types of services provided; and they wanted access to counseling and support through groups and classes.
- An inventory of existing local programs for families provided the basis for determining which FMO program activities best would address the identified needs. However, staff found, for the most part, that the majority of programs were limited in their applicability to the FMO for one or more of the following four reasons:
- they were categorically-funded, limiting the types of families eligible for services;
- they were specialized, only serving a specific ethnic population, language, condition, or age group;
- they were limited in their capacity to serve many parents, due to funding, staffing, or space constraints; or
- they were closing due to the lack of, or discontinuation of, funding.
- Searching for effective models on which to base the FMO. Staff focused on support-program models for possible inclusion in the FMO, since the great majority of parents who participated in the focus groups spoke to the need for parent education, information, referral, and support. Although no specific program emerged as a primary model, the study allowed staff to identify essential features for the FMO. These included the effectiveness of educating parents about child development as a way of reducing medical care utilization; the importance of addressing both the emotional support and the concrete information and skills needs of parents who are coping with specific medical or behavioral problems; and the impact of self-care to improve physical function, reduce pain, and lower health care costs.
- Studying family health-status measures. Issues that emerged as a means of measuring health status within families included immunization of two-year-olds, exposure of infants to the effects of adult alcohol and drug use and tobacco, childhood injury, and pediatric asthma. The adult behaviors selected as key influences on family health were substance use, smoking, domestic violence, child abuse and neglect, and mental health concerns.
- Conducting studies of utilization. Conducted at two different points in the planning process, the goal of these studies was to identify those patterns of use that might be inappropriately costly and that, with appropriate intervention, might be shifted to lower-cost alternatives. The first analysis was a comprehensive review of hospital-discharge and outpatient-services data for the publicly funded health care system, in order to identify specific family health conditions that appeared to be contributing to excessive medical costs. The second study consisted of a much more detailed analysis of hospital discharges and emergency room use in the Bay Point community, which had been selected as the pilot area for the project because of an initial finding of high outpatient and emergency room utilization and the presence of several activities that might be brought together in the FMO. The analysis showed that the availability of more appropriate or less costly treatment for asthmatics, diabetics, and Attention Deficit Disorder patients, as alternatives to routine outpatient visits were key areas for FMO attention.
The basic outlines of the FMO Program were defined by late 1995. Two FMO service components were designed to change the health care utilization practices of low-income families:
- Integrating several categorical public health and maternal and child health programs Child Health Screening, Prenatal Care Guidance, Child Health and Disability Prevention, and Public Health Nurse Home Visits into a parent education, outreach, and support unit for the Bay Point community. This unit would be responsible for increasing parent use of available family-practice resources (thus shifting care away from episodic, expensive emergency room treatment); providing culturally competent parent education and support to increase immunization levels, increase parents' child development understanding and parent-child/parent-parent communication skills; and addressing particular local family health risks.
- Combining case management resources with substance abuse and mental health staff to establish a "behavioral health unit" that would provide more personal intensive teaching and support to families that are high utilizers of medical services or users of multiple health and human service programs. This "behavioral health" unit would address the more severe adult behaviors that affect family health, including domestic violence, child abuse and neglect, and substance abuse.
- The FMO planning took place in a context of multiple efforts to improve outcomes for families in the county. Largely due to the work on the FMO project, the same broad family health outcome objectives were adopted by all county programs. The county health system is moving toward greater accessibility, both by adopting a more efficient appointment system and by exploring ways to open small, family-oriented practices in areas of the county not currently well served.
The project did not develop a fiscal plan sufficiently detailed to allow an estimation of the likelihood of success. Lack of sufficient progress was made clear by a site visit from a technical consultant toward the end of the grant. The reasons for this lack of progress include:
- Fiscal constraints. The planning process revealed the unavailability of resources to assist families in great distress, and the continued uncertainty of funding for the emerging programs limited the county's ability to launch the unified effort.
- Fighting over agency integration. The integration of services was also constrained by questions about the commitment and support of all the different agencies involved and whether or not they understood what the consequences might be for them. None seemed to have contemplated that the FMO might mean smaller staffs or less funding for their particular department. Bureaucratic resistance occurred as the departments involved came to realize that the FMO would mean smaller staffs and reduced funding.
- Departure of strong leadership. Competition for staff and decision-makers' time and attention because of the rebuilding of the county hospital was exacerbated by changes in personnel and leadership in all three departments most involved with the FMO. The DHS director who had a reputation for achieving results on ambitious projects spearheaded the FMO, and when he left for another job in Los Angeles, the attention to the FMO lessened during the transition to new leadership.
There was no dissemination of grant products outside of the Foundation.
AFTER THE GRANT
As a result of a Foundation staff site visit, the DHS planned a fiscal analysis of data to support a pilot program. After the conclusion of the grant, DHS spent several months exploring how data from multiple systems could be pooled to conduct a fiscal analysis. It became clear that incompatibilities across systems were insurmountable.
The DHS came to the conclusion that the FMO was too much of a reach at this time. In drawing from so many sources and attempting to combine health with a wide range of social services, the project was too inclusive to be practicable. Interagency integration was further complicated by the fact that money flows differently for medical care than for social support.
However, the thinking, data collection, and analyses that the DHS conducted during the FMO planning process has continued to inform ongoing conversations within the department about improving the health delivery system. The DHS is currently contemplating new funding alternatives for assisting high-need children, and ways of integrating medical care with various kinds of counseling, support groups, and group education activities in an HMO setting.
The recipients of these services have been expanded to include not only families, but also special populations such as chronic uncontrolled diabetics and the frail elderly. Finally, the county's health plan was selected recently by the Health Care Financing Administration to be one of the six new planning sites and the only site in California for Social Health Maintenance Organizations.
GRANT DETAILS & CONTACT INFORMATION
Development of a Family Health Maintenance Organization
Contra Costa County Department of Health Services (Martinez, CA)
Dates: April 1994 to December 1995
Report prepared by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: Nancy L. Barrand