SPE IS NOT A ONE WAY STREET
THE LARGER PICTURE
The
Case for Single Point of Entry
Rene
Lessard
Manager
Coordinated Claims Management
Alberta
School Employee Benefit Plan.
Paul Beaulne Ph. D. Candidate
Director,
RAI Canada Research Network
Faculty of Rehabilitation Medicine
University of Alberta
July
1, 1999
Table
of Contents
Implementing a
Single Point of Entry System
Steps in Implementing a Single Point of Entry System
Identification of Project Leader and Support Team
Determining the goals of the Single Point of Entry system
Identification of the desired Single Point of Entry approach
Client-Centered Approach
System-Centered Approach
Integrated Approach
Identification of a Single Point of Entry model
Minimal Model
Coordination Model
Comprehensive Model
Single Point of Entry Functions
Client Identification
Assessment
Service Planning
Service Linkage
Service Implementation and Coordination
Service Monitoring
Discharge Planning
Evaluation
Single Point of Entry Information Systems
Key function of Single Point of Entry Information System
Work Flow
Communication
Evaluation System
Existing Single Point of Entry Information System
Conclusion
References
The Case for Single Point of Entry
Despite the lack of a structured framework, health care experts view “Managed Care” as a viable approach to balancing the social-economic scale of efficiency and effectiveness of health care service delivery. In a recent document, Health Summit ’99 – An Alberta Framework for Discussion and Input- Albertans stated that they had concerns regarding the state of health care in this province. These concern are fueled primarily by 5 factors:
1. The number of high cost / high tech services are increasing.
2. Approaches to health treatments are changing rapidly.
3. Alberta’s population is expanding.
4. The relative number of older Albertans is increasing rapidly.
5. Consumers of the health care system have greater expectations then in the past.
In addition, health care services are managed by a diverse group of providers and agencies: Physicians, nurses, therapist, regional health authorities and boards such as the Alberta Cancer Board and the Mental Health Advisory Board. All these groups participate in coordinating and delivering health care services to Albertans. Overseeing this service delivery is the Minister and the department of Health. Even though, all these resources are available to Albertans, the system is still viewed has being inefficient and ineffective. Albertans have stated the following concerns:
1. Health services are not integrated.
2. Health professionals and providers do not work closely together.
3. Utilization of health resources is not controlled.
4. Levels of responsibility are not clear.
5. Sufficient evidence about what works and what does not work is not apparent.
Health care management groups agree that a primary goal of managed care is to balance efficiency and effectiveness. However, the absence of a structured and well defined framework has often lead to initiatives that are lacking long term goals and are mainly pushing cost containment to the forefront. A sustainable strategy would be an approach that does not shift with the economic environment or with an increase or decrease in utilization. The focus of any health care initiative should be one, that integrates the goals of health care system into a single structure and the foundation of such a structure is “Single Point of Entry”.
Most experts agree that Single Point of Entry is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates services to meet an individual’s needs through communication and available resources to promote quality, cost-effective outcomes[1].
Single Point of Entry is not a series of pre-determined events. It is a process, which needs to be flexible. For that reason, it has been difficult to obtain consensus in the health care industry as to how to implement a Single Point of Entry system.
Implementing an effective Single Point of Entry system in a health care is challenging at best. The absence of blueprints simply compounds the issue of developing an effective and efficient Single Point of Entry system. Single Point of Entry must be tailored to meet the needs of a certain population and/or demand within a complex health delivery system. While the functions of Single Point of Entry are similar regardless of the population served or at which organizational level it is implemented, several factors may shape its implementation. Factors such as:
1. The wealth and nature of services currently available.
2. To who does the above services report to?
3. How are they managed?
4. The existence of other Single Point of Entry systems.
5. The geographical area.
6. Available resources (Financial and Human)
Depending at what level the Single Point of Entry system is introduced; support for this initiative may or may not be entirely well received or accepted. As much as it is believed that teamwork exists within the healthcare industry, there is still a great deal of separateness among healthcare professionals. Doctors and administrators relationships are often adversarial, nurses continue their efforts in establishing their identity separate from physicians, clients of health services are isolated from the decision making process and other stakeholders such as; family members and other external care providers, often feel left out from the whole process. Therefore, in implementing a Single Point of Entry model, it is crucial that representation from all stakeholders groups be present and actively involved in the design and implementation of the Single Point of Entry system.
In the development of the Single Point of Entry system, stakeholders need to go beyond the team approach and move toward networking. Networking is defined as exchanging information or services among individuals, groups, or institutions in an effort to be proactive. Networking then becomes a very interactive process.
Implementing a Single Point of Entry system can be a considerable task. It can not be stressed enough that support and input from stakeholders is required in order to achieve the desired results. The designation of a project leader is crucial to the development and implementation of such a project. This individual must ensure that a win-win attitude is maintained throughout the entire process. Negotiation, facilitation, and excellent communication skills are essential attributes the project leader must possess.
Some people or organizations may resist the development and implementation of a Single Point of Entry system, therefore choosing team members for the project must be done carefully. Choose a room full of champions! The team should consist minimally of an individual who has authority to approve some of the decisions made by the team, one who is task oriented, one who is a big picture thinker and also one who may not be in total support of the project. This last person can be helpful in identifying certain sensitive areas where emphasis may need to be placed. Note that the support of the team may not be enough, if the support of authority and physical/financial resources are not present.
In order to determine the goals of the Single Point of Entry system several steps must be undertaken with the team.
a) Conduct an audit of current systems.
i) Identification of services within the existing system(s).
ii) Identification of service gaps or deficiencies.
b) Identification of client needs.
c) Setting service priorities.
d) Define objectives and deliverables.
Once the above are determined a Single Point of Entry approach must then be agreed upon. Single Point of Entry has three distinctive approaches.
1. The Client-Centered Approach.
2. The System-Centered Approach.
3. The Integrated Approach.
The client-centered approach recognizes that the current health care system is far too unfriendly and complex for clients to navigate. It also acknowledges that clients of health care services are often vulnerable and passive in the health care process. This approach focuses on service provision as oppose to service delivery.
The system-centered Single Point of Entry approach recognizes that today’s health care dollars and resources are limited. This approach focuses on cost efficiency and is usually concerned with service delivery versus service provision.
In order to be
effective, Single Point of Entry must set priorities as to who receives
services, how these services are provided and by whom.
It is evident that the Client-Centered and the System-Centered approaches
are somewhat at odds with each other. The
Integrated Approach ensures that clients have access and receive appropriate
health care services in a cost-effective manner.
To complicate things further, several models for Single Point of Entry exists. To simplify the number of models available, we will restrict ourselves to the following three models:
1. Minimal
2. Coordination
3. Comprehensive
The minimal simply provides for populations where services are provided on a one-time basis. The client is assessed, services are planned and appropriate referrals are made to service providers. The Single Point of Entry process is then completed. The minimal model is often offered where needs are episodic in nature.
In the coordination model the client is assessed, services are planned, referrals to service providers are implemented and a case manager remains with the case for monitoring purposes. Such a model often exists where needs are somewhat more complex but of shorter duration.
The comprehensive model is by far the most complex to implement. Beyond assessing, planning and referring clients to other services, the comprehensive model continues to monitor the individual throughout a continuum of care. The clients often enter the system through a single point of entry and are managed until recovery or until the client is deceased. This system is often seen within services for the elderly. This comprehensive system ensures the client transitions between services according to their ongoing assessed needs. This model offers the most in terms of accountability.
The determination of the client’s eligibility to participate in the service must be identified at the onset. This is normally accomplished through the review of referral information and through an initial interview. These greatly depend on the how clients interacts with the services. Are clients referred on a case by case basis, through a continuum of care model, or through a single point of entry model. Regardless of the referral process, the first step of the Single Point of Entry process is to identify the target population based on pre-determined criteria. These criteria may change has the Single Point of Entry system is being evaluated for its efficiency and effectiveness.
The
assessment process determines the course of the Single Point of Entry program
for the client. Assessment information is accumulated that will determine the
client’s present level of functioning and needs. This assessment leads to the
establishment of an individual service plan. Assessment tools may vary based on
the client’s needs and based on the Single Point of Entry model.
For example, the minimal Single Point of Entry model may simply use a
diagnosis as a form of assessment and the diagnosis determines the course of
action for the rest of the client’s involvement in the system. With the
comprehensive model, several assessment tools or one assessment tool geared to
evaluate client needs throughout the continuum of care is essential.
Service planning
and resource identification are dependent on the information attained in the
assessment process. Case managers in this component must ensure client participation and
serve as the primary service planner. Therefore,
the case manager must be cognizant of all activities surrounding the service
plan and must be aware of all resources available to meet the client’s needs,
internal and external to the program.
Linking clients to required services goes beyond arranging for services and making necessary referrals. It requires the completion of steps necessary to ensure the client will attend planned services. It also requires the Single Point of Entry approach to have identified an adequate service provider network.
Coordination is defined as arranging something “in the proper relative position” or carrying out a complex task through “harmonious adjustment or interaction” (American Heritage Dictionary, 2d Ed.) This component involves ensuring that the service plan is carried out as agreed by the identified providers or by an interdisciplinary team. Coordination also involves troubleshooting with the service provider or with external support services. The case manager must make sure that all goals and objectives are prioritized and are carried out in a logical manner. This component involves documentation through vehicles such as case notes and may involve formal and informal meetings with the service provider, the interdisciplinary team or external support services.
Monitoring involves overseeing and supervising in order to obtain specific information relevant to the individual plan. This is done at predetermined intervals through regular communications with the service provider or through attendance at interdisciplinary meetings. The purpose of monitoring is to ensure that the client continues to receive the appropriate level of service and that these services are meeting the identified needs and the general program goals.
Continuous monitoring may result in a re-assessment of the client’s needs and a revision of the service plan. It may also identify that all is well with the present service plan and that goals and objectives are on track. Monitoring may indicate the clients needs have been met and that discharge planning should take place. It is crucial, for this component to be successful, that the service provision and coordination is cohesive in its approach with the client and is willing to share and accept responsibility in the client’s care.
One of the primary goal of Single Point of Entry is to ensure that individuals who no longer require a service are identified as soon as possible. Dependent on the Single Point of Entry model and the population served, discharge planning may start at the early stages of the Single Point of Entry system. Just as it is crucial to determine criteria for those who require services it is equally important to identify criteria for those who no longer need the services.
Just as monitoring is important in the Single Point of Entry process so is evaluating the overall Single Point of Entry strategy on an ongoing basis. In order to accomplish this function the Single Point of Entry process must be well documented throughout. The use of a computerized Single Point of Entry tracking system is often helpful in determining the outcomes of a successful Single Point of Entry model.
Single Point of Entry seeks to ensure clients are receiving required services in a cost-effective manner. This can be overly challenging for any case managers to ensure on a consistent basis. Secondly, in order to evaluate the Single Point of Entry system information regarding clients, services received, financial information and outcomes must be readily available. The information system must also act as a reminder to the case manager of the steps required in developing an effective and cost efficient service plan.
Success is tied to the ability to access and organize the information needed to perform the functions of the Single Point of Entry model. The Single Point of Entry information system acts as a tool to tie in all activities throughout the life of the client within the Single Point of Entry process. For example, an individual with a stroke may be treated through emergency, the hospital for acute services, a rehabilitation program, home health and finally as an outpatient. This course of services may occur over an extended period of time. Today, this individual would be transferred from one course of treatment to another with no one system or person accountable to ensure that the client receives the appropriate level of care at the right time. Therefore, it is extremely difficult to comprehensively track the clients through the continuum of care. This lack of coordination often results in duplication of care because there is no interactions between processes.
· Work Flow
· Communication
· Evaluation System
Work flow is where the information system will have its most profound effect. Integration of continuum of care models within the system will assist the case manager perform the necessary functions of Single Point of Entry in an orderly manner. For example, an individual identified to receive home care services would be entered within the system. The individual’s demographic information would be entered and be readily available to the case manager. Once the individual’s needs have been assessed, this information is entered within the system. A service plan is developed and resources based on the needs of the individual are readily identified. Authorized service providers are listed in the system for the case manager to select. Referral information can easily be transferred to the chosen service provider and the case manager can set up progress reporting cycle times to monitor the individual progress. Progress cycle times can be chosen based on pre-established intervals or based on a continuum of care model. Case notes can be maintained and further assessment reports or additional services can be tracked. With the above information the case manager can investigate alternate service delivery should the current services no longer meet the needs of the individual. All information is contained within one system. Financial information as per cost of services is once again readily available.
The Single Point of Entry information system can allow the case manager to communicate electronically. It can assist the case manager in reporting progress to appropriate stakeholders. Existing Single Point of Entry information system have features where standardized letters are designed and all required demographic information are automatically transferred to the letter for easy and consistent communication with stakeholders.
Stored information can easily be retrieved and reports can be generated on a regular basis to evaluate the Single Point of Entry system. At the inter-organizational level a review of service utilization and cost can easily be performed. At the intra-organizational level resource allocation and service delivery gaps can easily be identified. For example, if found that most clients of home health services require dietary education; the organization may wish to procure these services as part of their service delivery. At the client/provider level the evaluation may identify further training required or adjustments in the service delivery including additional assessment or alternate treatment methods.
Many Single Point of Entry information systems currently exist. Most systems are geared toward a specific client or diagnostic group. When investigating the purchase of an existing system the buyer should ensure that their current technology can accommodate the requirements of the off the shelf system. Training in the utilization should be provided and assistance in populating the system with existing client information should be given. A successful Single Point of Entry information system must be flexible to adapt to ongoing information needs and changes within service delivery.
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The current health care delivery system is complex and difficult to navigate. The implementation of a Single Point of Entry system would assist the clients in obtaining the right services at the right time and assist the provider of health care services to determine areas where efficiency could be realized. Single Point of Entry is an extremely simple concept; however, due to its diversity it is crucial to identify a specific approach before developing such a system. It is important to also ascertain at what level will Single Point of Entry be introduced. The Single Point of Entry system may be introduced at one organizational level with a long-term goal of introducing it at other levels later in the designing phase. If this is the case, the design and planning of the Single Point of Entry system must take this into consideration at the onset.
A solid Single Point of Entry information system will assist both the case manager in accessing information regarding their client in a timely fashion as well as providing the case manager with the tools necessary to make sound decisions. The Single Point of Entry information system must also provide those who will evaluate the benefits of the system with information that will identify the deliverables.
Given that the objectives of Single Point of Entry is both ensuring the provision of quality and efficient in a cost effective manner, the designer of the program will be challenged on all sides when developing the program. The payer will want to ensure cost control; the providers will want to ensure quality care. Both parties will have to be reminded that Single Point of Entry can be the tool that reconcile what is considered two very conflicting ideologies.
(In summary, segregation of function and accountability is to some extent seen because Single Point of Entry is still in its infancy and is often not well established across the continuum of care. What is often witnessed is that highly effective service delivery within an area is sometimes compromised by the lack of an integrated cases management system. For example, the authors recently reviewed the effectiveness of the CHOICEã program; a health program designed for the care of Frail Elderly. In the review it was identified that clients were transitioning between levels of the health care system with no overall accountability or long term outcome goal established. The CHOICEã program received what would be considered to be the highest in praise for the effectiveness of care within the program. However, no one individual or organization was responsible for the overall outcomes achieved by a client and ensuring a smooth transition from one service area to another.)
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[1] Individual Case Management Association (July, 1991). National Case Management Task Force Steering Committee.