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Service Delivery Innovation Profile

Technology-Enabled Reengineering of Referral Intake Process and Case Management System Significantly Improves Field Nurses' Ability To Serve At-Risk Families


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Snapshot

Summary

The County of San Diego Health and Human Services Agency implemented a Mobile Remote Workforce project to increase the amount of time field nurses in the agency's public health nurse home visitation program can spend providing direct services to at-risk families. The technology-facilitated project streamlined the referral intake process, transferred referral processing to administrative staff, and provided better support to field nurses through a revamped case management system. The project increased the number of client contacts, improved timeliness of care, increased client and staff satisfaction, and reduced costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of an independent evaluation using a regression-discontinuity design, including an experimental group and a "control" group that implemented some of the changes that the experimental group implemented.
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Developing Organizations

Center for Management Science, University of California, San Diego, School of Medicine; County of San Diego Department of Human Resources; County of San Diego Health and Human Services Agency, North Regions; Northrop Grumman; Palomar Pomerado Health; Pennant Alliance; Tri-City Medical Center
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Use By Other Organizations

Several other departments within the County of San Diego Health and Human Services Agency recently embarked on similar business process reengineering projects to improve service delivery, including Aging and Independence Services and California Children Services. Both departments utilize the same Web-based site as the Mobile Remote Workforce, saving on costs and allowing customers to access several services at the same time. In particular, California Children Services is a State-mandated program that facilitates the treatment of children with certain physical limitations and chronic health conditions or diseases. Before the reengineering project, public health nurses in the department evaluated complex medical referrals to determine medical eligibility of children referred for services. Frequently, these referrals were inaccurate, duplicative, and lacking essential medical information for a timely medical assessment. As a result, the County was not meeting California State Department of Health Care Services mandatory 5-day response time. The Health and Human Services Agency reengineered the referral process and developed an electronic Web-based referral system that reduced the average time for medical determination to only 2 days. The time required to approve a full application went from 28 days to 7 days, while duplicate referrals dropped from 6.4 per client to 0.15 per client (clients received multiple referrals for different procedures).

Date First Implemented

2005
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Patient Population

Vulnerable Populations > Rural populationsend pp

Problem Addressed

Administrative demands, including an inefficient referral intake process and case management system, frequently impair the ability of public health nurses to provide direct services to at-risk families with children.
  • Inefficient referral intake process: At San Diego County's Health and Human Services Agency, an inefficient referral intake process and case management system limited the amount of time nurses could spend visiting clients' homes in the six geographical regions served by the agency's public health centers.1 The referral intake process had several problems, including use of multiple methods for sending referrals (e.g., phone, fax, and mail), referrals going to the wrong public health center, incomplete and/or inaccurate referrals (e.g., missing or wrong name and/or contact information), and inappropriate referrals (e.g., the client needed other services). The net result was significant delays in processing and excess time being spent by nurse supervisors to correct the problem. Due to the transient nature of the population served, by the time nurses attempted to contact clients, their contact information had often changed, leaving nurses unable to locate them.
  • Burdensome administrative requirements: Nurses were spending an excessive amount of time on mandatory case narrative and charting, scheduling, travel, and other administrative functions, leaving inadequate time for direct client service.2 For example, every time a nurse received a new case, he or she had to travel back to the main office to get the relevant information.

What They Did

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Description of the Innovative Activity

San Diego County's Health and Human Services Agency developed a multipronged, technology-facilitated program designed to streamline the intake process, transfer referral processing to administrative staff, and better support nurses in the field through a revamped case management system. Key program elements include:
  • Referral intake process: The agency developed an accurate, complete, and appropriate referral system to reduce delays in processing referrals and increase the amount of time nurses can spend performing home visits. The information needed to process referrals and the criteria for appropriate referrals are now standardized across the six regions of San Diego County. The system, which was initially paper-based, is now Web-based, with referral agencies filling in several required fields (e.g., contact information, zip code) in the Web-based system, thus ensuring more complete referrals and enabling the system to automatically direct referrals to the appropriate health center based on the zip code entered.
  • Leveraging clerical staff: The agency trained clerical staff to process referrals. The clerical staff use eight broad parameters that were developed by nurses to help identify inappropriate referrals; these parameters help in identifying conditions that are not within the scope of the program (e.g., treatment for head lice). This change liberates nurses to focus only on appropriate referrals.
  • Technology-enhanced case management system: The agency developed an electronic case management system, known as PHIX (Public Health Nurses in the Community), that automatically assigns new referrals to the appropriate public health center based on the geographic location of each client. Public health nurses in the field use handheld tablets that wirelessly link to the database, thus eliminating the need for them to travel back to the office in between field visits to learn about new cases or update the status of existing ones. This system is crucial in enabling nurses to be a mobile remote workforce, which is especially important for serving rural areas, such as American Indian reservations. It allows referral agencies to easily track the status of their referrals and public health nurse supervisors to monitor their nurses' caseloads. As of February 2013, the agency has chosen to procure a software product called Persimmony which will enable the electronic health record to meet nursing documentation and case management system needs along with providing additional capabilities. A gap analysis was conducted and it was determined that the PHIX application can be retired and the impact to replace this application will be minimal. Persimmony will allow public health nurses to capture health related information for clients as well as individual and community outcomes. Persimmony software can also be used to submit targeted case management reimbursement billing to the state and send client data to the Nurse-Family Partnership (NFP) program through a live feed to NFP Efforts to Outcomes database. The agency is collaborating with Persimmony to build all necessary components within the software application.

Context of the Innovation

The County of San Diego Health and Human Service Agency operates a nurse home visitation program where public health nurses travel to the homes of at-risk families with children, providing face-to-face services. Nurses primarily serve low-income, medically uninsured, and underinsured families, many of whom have histories of substance abuse or spousal abuse and have children at risk for abuse or neglect. During home visits, nurses conduct health assessments for pregnant women; perform developmental testing of infants; provide information about healthy growth, nutrition, and safety; teach parents skills for raising infants discharged from neonatal intensive care units; and refer families to other agencies for follow up services. As part of a county-wide initiative to introduce business process reengineering to improve the quality of programs and services, the agency asked the Public Health Department to take a close look at its business practices. An in-depth review of public health nursing processes identified a number of problem areas and opportunities for improvement, which ultimately led to the idea of a Mobile Remote Workforce initiative to reduce the number of unsuccessful client contacts and improve the referral process.

Did It Work?

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Results

An independent evaluation conducted by the Center for Management Science, University of California, San Diego, compared pre- and post-implementation data to show that the program resulted in measurable improvements in the number of client contacts, timeliness of care, and client and staff satisfaction, along with reductions in costs. The evaluation collected data at baseline, as well as at the conclusion of the 12-month pilot project.
  • More clients served: The number of clients served increased by more than 27 percent, with 2,400 additional clients served annually.
  • More timely service: The amount of time it took for referrals to reach nurses fell to 1 day for all referrals, compared to a 1- to 18-day wait before the program's implementation. The average amount of time between nurse receipt of a referral and client contact went from 30 days to 6 days, an 80-percent reduction. The number of first contacts made within 1 month initially increased by 50 percent, from an average of 11 first-month contacts each month before the program to 17, with a sustainable increase of 25 percent. The number of nurse visits resulting in no service provided decreased from 33 percent to 4 percent.
  • Enhanced customer and staff satisfaction: Staff reported enhanced satisfaction due to the ability to complete paperwork and get new assignments while still out in the field. The average responses by nurses and clerical staff on a 5-point Likert scale indicated that they were "satisfied" or "very satisfied" with the new processes. Customer satisfaction rose to 100 percent, with survey respondents expressing a desire for the system to be used for all county services.
  • Lower costs: A cost-benefit analysis of the project rollout achieved a 29-percent (from $965 to $681) savings in the unit cost of each public health nurse visit.

Evidence Rating (What is this?)

Moderate: The evidence consists of an independent evaluation using a regression-discontinuity design, including an experimental group and a "control" group that implemented some of the changes that the experimental group implemented.

How They Did It

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Planning and Development Process

This pilot project was completed in 12 months, divided into three transitional phases followed by a data-collection phase. Key elements of the planning and development process were as follows:
  • Assessment of existing operations (phase one): Between February 1 and June 30, 2005, a design team consisting of nurses and staff from the pilot sites, in consultation with the Center for Management Science at the University of California San Diego School of Medicine and information technology representatives, completed the operational assessment and developed a plan to reengineer the referral process. The design team established new policies and procedures creating accurate, complete, and appropriate referral standards. The team also developed a preliminary funding plan for pilot project implementation. The Health and Human Services Agency contracted with Pennant Alliance to develop a Web-based referral system, and the design team held weekly meetings to track the implementation of the new referral process.
  • Operational process enhancements (phase two): Between July 1 and September 30, 2005, project leaders established pilot and control groups. The pilot group implemented the process reengineering after receiving training on the accurate, complete, and appropriate referral standards. Relevant staff discussed new duties, responsibilities, and procedures to ensure compliance with the required changes. Clerical staff tracked all referrals, and public health nurses completed detailed time studies that replicated baseline data gathered under the guidance and instruction of the Center for Management Science at the University of California San Diego School of Medicine. Project leaders identified major referring agencies for participation in the Web-based referral system and provided them with training. They also implemented the redesigned forms and streamlined operational procedures and PHIX case management software, thus completing the business process reengineering.
  • Implementation of technological enhancements (phase three): Between October 1, 2005 and January 31, 2006, the control group began applying the accurate, complete, and appropriate referral standards to all referrals but did not use the Web-based referral system. This enabled measurement of the Web-based referral system's contribution to the improvement of the referral process. The pilot group implemented the PHIX software application, which was made available to public health nurses in the field using the electronic tablet. Nurses received extended training on the use of the electronic tablets and the PHIX application.
  • Data collection: At the conclusion of phase three, the Center for Management Science at the University of California San Diego School of Medicine gathered performance data and compared the results to baseline data gathered in the first two phases. This two-tiered methodology enabled results of individual aspects of the pilot project to be evaluated separately.
  • Ongoing enrollment of and training for referral agencies: As of August 26, 2013, the program has trained 115 referral agencies to use the PHIX Web referral system. Public health nursing administration continues to provide training to community agencies, as well as to internal departments. Public health nursing managers, supervisors, and office assistant staff notify the project manager of any agencies that are interested in obtaining access to PHIX Web. The project manager coordinates with each agency to schedule a date to visit and train any interested staff. Audience numbers in these trainings can range from 1 to a group of 30.

Resources Used and Skills Needed

  • Staffing: The program required a program manager to oversee the pilot project; the Mobile Remote Workforce committee (including the Deputy Director of North Regions; the chief technology officer; the director of public health operations; and representatives from administration, finance, privacy/compliance, human resources, and labor unions); contractors to participate in design, technology enhancements, and evaluation; county and private sector experts to provide technical architecture and automation enhancements; public health nurses (12 full-time equivalents for the pilot project); and clerical staff to be in charge of the referral intake process. Most of these individuals participate as a part of their regular duties, although the outside contractors were hired specifically for the program.
  • Costs: Total program costs were approximately $844,000, including $824,000 for program development and equipment and $19,800 for program evaluation.
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Funding Sources

County of San Diego
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Tools and Other Resources

The Mobile Remote Workforce Web referral portal, known as PHIX, can be found at https://phnsdcounty.us/phixweb/.

Adoption Considerations

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Getting Started with This Innovation

  • Examine current practice: Identify the process or processes in need of reengineering by conducting an indepth review of current practice.
  • Seek involvement from stakeholders: Involve all appropriate parties, including an independent evaluator, providers, finance representatives, and other agencies that will ultimately use the improved processes.
  • Create, and follow, a plan of action: Develop a detailed action plan with outcomes and target dates. Conduct additional process mapping of targeted processes before determining the appropriate direction and changes.
  • Test changes before finalizing new technology: Test the newly reengineered process first, deferring technological enhancements until later. Take time to assess the new processes through a pilot test, and make adjustments as necessary.
  • Keep timelines realistic: Establish realistic timeframes for testing and development of new technologies.
  • Consider opportunities for collaboration: Share resources and expertise with other departments and agencies engaged in obtaining the same goals and/or serving the same population. Another County of San Diego Health and Human Services Agency reengineering project (see Use by Other Organizations for more information) partnered California Children Services with major hospitals to link agency and hospital demographics on matching customers to increase efficiency and reduce redundant records.

Sustaining This Innovation

  • Establish continual compliance checks: Implement ongoing auditing to ensure continued compliance to standardized procedures that are a part of the reengineered process.
  • Emphasize training and education for staff and partner agencies: Continually educate providers and public health staff on the new referral processes.
  • Seek sustainable funding: Identify sustainable financial resources, particularly for ongoing technology maintenance and enhancement.
  • Make use of revenue sources: Link services to revenue sources as much as possible. For example, the public health nurses tie as many of their duties as possible to services covered by specific revenue sources.

Use By Other Organizations

Several other departments within the County of San Diego Health and Human Services Agency recently embarked on similar business process reengineering projects to improve service delivery, including Aging and Independence Services and California Children Services. Both departments utilize the same Web-based site as the Mobile Remote Workforce, saving on costs and allowing customers to access several services at the same time. In particular, California Children Services is a State-mandated program that facilitates the treatment of children with certain physical limitations and chronic health conditions or diseases. Before the reengineering project, public health nurses in the department evaluated complex medical referrals to determine medical eligibility of children referred for services. Frequently, these referrals were inaccurate, duplicative, and lacking essential medical information for a timely medical assessment. As a result, the County was not meeting California State Department of Health Care Services mandatory 5-day response time. The Health and Human Services Agency reengineered the referral process and developed an electronic Web-based referral system that reduced the average time for medical determination to only 2 days. The time required to approve a full application went from 28 days to 7 days, while duplicate referrals dropped from 6.4 per client to 0.15 per client (clients received multiple referrals for different procedures).

More Information

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Contact the Innovator

Nick Macchione, MS, MPH, FACHE
Director, Health and Human Services Agency
1600 Pacific Highway, Room 206
San Diego, CA 92101
Phone: (619) 515-6545
Fax: (619) 515-6556
E-mail: nick.macchione@sdcounty.ca.gov

Innovator Disclosures

Mr. Macchione has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Background information on the Mobile Remote Workforce project pilot, awards, presentations, as well as professional publication and article links can be found at http://www.sdcounty.ca.gov/hhsa/regional_admin/north/mobile_remote_workforce_innovation.html. Some examples include the following:
  • Lake A. Nurses without wires. Government Technology. July 6, 2006. Available at: http://www.govtech.com/magazines/gt/Nurses-Without-Wires.html
  • Macchione N, Shepard J. Improving health care access in San Diego County. The Public Manager. 2006 Summer;35(2):25-8.
  • Lamont J. KM tackles tough e-gov challenges. KMWorld. May 30, 2007. Available at: http://www.kmworld.com/Articles/PrintArticle.aspx?ArticleID=36248

Footnotes

1 County of San Diego Health and Human Services Agency. Mobile Remote Workforce: Background [Web site]. Available at: http://www2.sdcounty.ca.gov/hhsa/documents/MRW3Background.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 County of San Diego. Mobile Remote Workforce Innovation for Health & Human Services: Using Business Process Reengineering To Increase Productivity [Web site]. 2006. Available at: http://www2.sdcounty.ca.gov/hhsa/documents/MRWonepager06-09-06.pdf
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Original publication: April 28, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 14, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 03, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.