**FTS-HRSA OA**

**October 28, 2003**

**8:05 a.m. CST**

Coordinator Good afternoon. Thank you for standing by. All participants
will be able to listen-only until the question and answer session of the
conference. This conference is being recorded; if anyone has any
objections you may disconnect at this time. I would like to introduce
your host for today's conference, Ms. Claudia Lacson. Ma'am, you may
begin.

C. Lacson Good afternoon, everyone. My name is Claudia Lacson, and I am
part of the Rural Health Network Technical Assistance Team at the
Georgia Health Policy Center in Atlanta. As you all may know, the topic
for our teleconference today is, "Demonstrating Benefits To Your Network
Members." The presenter that we have that I have the pleasure to
introduce today is Greg Bonk, who is the President of HMS Associates in
New York State. Greg has 13 years of experience consulting with rural
health networks, and has managed several rural health networks himself
in a statewide technical assistance program for about 25 years.

> All of his clients include Critical Access Hospitals, State Offices of
> Rural Health, and the Federal Office of Rural Health Policy. He has
> conducted studies on clients, including Critical Access Hospitals,
> Network ..., Critical Access Hospital Conversion, and has also
> authored a publication on Principles of Rural Health Network
> Development for the Academy of Health Services Research.

Along with Greg we have a group of panelists who will be complementing
his presentation, and they are: Buzz Davis, a well-known Rural Health
Network Consultant that may be familiar to some of you, and Margaret
Jackson, the Director of the Vermillion Parish Health Network in
Louisiana.

As you all may have seen in the previous e-mail that Rebecca Hines sent
last week, this call will consist of three phases. Phase one will be a
presentation on the key concepts for developing networks, collaboratives
and partnerships. Phase two will be a presentation on tools for mapping
member interests and benefits. Phase three will be on network management
concepts and tips. Each phase will be taking about 25 minutes, and there
will be five to ten minutes for the panelist's participation, and
questions and answers from the rest of the participants on the call.

Without further ado, I will leave with our presenter for today, Greg
Bonk.

G. Bonk Thank you, Claudia. I hope most of you had a chance to load the
PowerPoint demonstration on your computers, because what I'm going to do
is go through those various slides. I'll give you an idea when I'm
switching from slide to slide, so not only will you have the pleasure of
hearing my voice, but you can also follow the presentation on your
computers through the slideshow.

I hope that you've all had an opportunity to view it, and I hope that
the attachments that have been provided with the program are all
useable. In particular, the list ... universe of potential network
services that a lot of organizations have found very helpful, just to
get some sense of what potential really looks like out there. Then the
"benefits mapping software," which is a tool that helps organizations in
particular networks get a good sense of the importance of their various
objectives to their members, a sense of the benefits that members expect
to accrue as a result of participating in the particular objective. Then
the final sheet in that little software piece is a listing of potential
roles that network members can play relative to a variety of objectives.

As I look at the slide presentation, I'm kind of moving along to slide
number three because it's my understanding we've got three different
groups participating in the call this afternoon. First and foremost, all
of the rural health network grantees have been invited to participant,
and when it comes to these kinds of participants, what we hope to
impart, myself and the other panelists, is a sense of how to wade
through all of the issues that you face on a day by day basis, and focus
your energies and your members energies on those programs that are most
critical to your success. Especially, always kind of in the back of your
mind have the concept of how you think your members are going to benefit
from each particular program or function you're providing.

There are a variety of tools in here, we think, that can help you
accomplish that. Secondarily, for state offices of rural health, the
discussion regarding collaboration and networking has been found to be
useful because it looks at collaboration from kind of a functional
context, and when I say functional context I mean that the various
organizations involved in the network or collaborative are really there
because they're performing a unique function that adds to the success of
a network effort. Then as you look at promoting multi-organizational
activity in your communities and states, we think it's a good idea to
look at it from the context of what does each particular kind of
organization bring to the table? What are your expectations relative to
the participation of various types of organizations?

> Then thirdly, there may be some flex critical access hospital people
> on the line, and within the context of that program, there's clearly a
> relationship between the critical access and the support hospital. As
> we go through some of the concepts on collaboration and get into the
> detail of universal potential functions there may be some functions in
> that list that may be worth pursuing with support hospitals or other
> critical access hospitals to really help strengthen your overall
> position in the rural health market.
>
> So my comments are going to address those three types of participants,
> with having emphasis on the actual networks themselves, because what
> I'd really like to convey is not only some of the theory and
> principles that are present in the presentation, but also talk about
> some real world issues, talk about a lot of anecdotes of experiences
> that we've seen in different parts of the country and with different
> kinds of networks, with the intent of going from theory to practice so
> there's a good conveyance of how the theory relates to the real world
> of network operation.
>
> As we move along to slide four, I've ask for the networks just to
> spend a little time, in advance, thinking about what your network
> members really want to get out of participating in the network
> activity or in the collaborative, because that's really very, very
> central to the discussion here. As we get into the question and answer
> period later on there may be some questions that you have regarding
> the whole benefit model, how do you actually come up with benefits for
> members that we can respond to and provide some practical tips on
> things you can do next.
>
> After looking at benefits, the next question is, what are your
> obstacles to getting there? Clearly, in the world on network
> development it's not a linear path, it's certainly not a step one,
> step two, step three path, our experience is that the real issue is to
> identify a plan, identify who should do what, and move on it, and
> recognize that you're going to have to make adjustments along the road
> because that's the very nature of what we're dealing with here,
> change, and change in a relatively complicated environment.
>
> Again, finally, at the end of the presentation there will be a time
> for you to ask about the whole issue, identification of benefits, to
> maybe explore this whole concept of fast tracking objectives. What we
> mean by that is that in some instances, and this is been a historical
> perspective on network development, organizations spend one or two or
> three years doing forming and storming kinds of activities, during
> which they're trying to kind of establish a mission.
>
> In our view, that time can be better spent if one comes to a sense of
> what one wants to accomplish relatively quickly, a month or two or
> three, and then get down to the business of trying to do something
> about it. We think that that's the best way to pursue network
> development rather than spend a lot of time on examination or
> priorities and network interests and so forth, because the true test
> of sustainability, from our view, is the fact that you're delivering
> benefits to your members. And as they recognize those benefits and the
> importance of those benefits, they're going to be more interested in
> sustaining the network through a host of mechanisms, some that may
> pertain to a dues or a fee structure, something that may relate to
> participating in a revenue generation capacity. Then, finally, some
> that really may relate to attracting other forms of funds, which will
> enable organizations to continue to provide services that are really
> needed in their communities.
>
> Moving along here, trying to pick up the pace, again, we've got three
> stages to what we're going to talk about this afternoon. One is kind
> of the theoretical piece on key concepts, and although they're
> theoretical we find they're essential because there is some statements
> in here that we think a lot of organizations need to hear that at
> times are ignored, but really help people think through what they're
> going to accomplish.
>
> Secondarily, we'll talk about tools, and that is the checklist and the
> benefits mapping. Then finally, some concepts and tips on how you
> manage a network. Key questions like what happens when the influential
> people on your board are at war? What do you do in those instances,
> how do you continue to stay on track when things like that happen?
> Questions like, the big issue in our group was getting the grant,
> that's what we thought was the big outcome for the activity, well,
> where do you move after that? What types of things do you want to look
> at next? Then, finally, we'll have time for a question and answer
> period.
>
> Moving into slide six. The key concepts we want to look at are
> collaboration as a means for change, because that's really, in my
> estimation, what networks are all about, they're change mechanisms. As
> organizations that are really promoting change, there are a lot out
> there, and as an organization looking at change you face everything
> that everyone else faces when you're trying to bring about change,
> that is moving away from the status quo. The key piece here is that
> you've got multiple parties trying to accomplish change, which
> represents its own set of challenges, looking at some principles of
> collaborative action, and then some lessons that we've learned from
> the field, which drawn on about 13 years of network experience with
> something in the neighborhood of like 75 different networks, various
> types and sizes, different parts of the country and so forth.
>
> As we move into slide seven, we find it's very, very worthwhile to
> always keep in mind that the fundamental nature of a collaboration or
> a network is that no single agency can accomplish the goals or
> objectives that the network is involved in. It seems like a fairly
> simple idea, but invariably it's led to a lot of discussion in
> networks we've worked with and it needs a lot of reinforcement.
> Basically, from our view, we think that collaboratives or networks
> should only be involved in projects that require the participation of
> multiple organizations, hospitals, community health centers, public
> health departments, etc. If a single agency in a community can
> accomplish the objective that a network is addressing, from our view,
> the network shouldn't address it because you don't need a network
> structure to accomplish the goal.
>
> One can take this argument a little farther, to the extent of which
> can a single agency accomplish it as well? In that instance, I think
> that's where the network comes into play. Some organizations may think
> or may want to accomplish something on their own, but in fact don't
> have the capacity to do so, and that's what the general potential of a
> collaborative or network represents, an opportunity to bring in
> different parties who have different capacities when joined together
> give you the best chance for the highest quality outcome.
>
> The next point that pertains to the real type of collaborative
> activity that occurs, and the distinction between horizontal networks
> and vertical networks. Some may think that this distinction is kind of
> academic and it's not very significant in the grand scheme of things.
> Our view of it is that it's a rather critical distinction, and a
> distinction that affects how networks do business. The horizontal
> network is the network that's made up of the same type of healthcare
> providers. That is you have a group of hospitals, or a group of
> community health centers, or a group of public health departments, and
> everybody in the network is the same kind of an agency, and that's the
> horizontal network.
>
> The other type of network is the vertical type of network. Then your
> vertical type of network you've got different kinds of providers
> involved in the same objective. You have health centers, you have
> clinics, you have hospitals, but you've got different types of
> organizations involved. I'll go into the distinctions a little more in
> the next couple of slides, but fundamentally, the key driving force in
> the collaborative is that the agencies are going to collaborate to the
> extent to which they, and the communities they serve, benefit directly
> from participation. I'll get into the issue of benefits in much
> greater detail.
>
> We move into slide eight. Slide eight helps to kind of show the
> distinction of this collaboration that's of the horizontal nature and
> of a vertical nature. If you have a Macintosh computer, the slide is a
> little out of whack; there's not a really good fit between some of the
> graphics between those two programs. But what this slide kind of
> illustrates is that when you have individuals from different types of
> organizations involved, that's "the vertical network," and when you
> have organizations of the same type involved that's the hospital or
> horizontal network.
>
> Again, you've got a similarity of members in horizontal networks, and
> a different type of member in a vertical network. Those two features
> generally suggest that the things that the networks do are very, very
> different. I'll appreciate hearing from the members of the panel on
> this point later on. But when you look at horizontal networks,
> networks made of say hospitals or community health centers, generally
> they're involved in services that are going to increase efficiencies
> or relate to economies of scale, and effectively performing functions
> that they all must perform in a similar way, be a quality assurance,
> be an emergency room coverage, etc.
>
> Networks of that type are more sustainable from the context of a dues
> or fee structure because, in effect, the network is providing a
> service to the hospitals or community health centers or public health
> departments in that particular network. As you shift into the vertical
> context, the commonality of members in a vertical network, as far as
> HMS is concerned, is more of a commonality of an attempt to integrate
> service delivery in a particular community. Your horizontal networks
> can be made up of providers that are all over the state. They may be
> contiguous areas, they may not be, but they're generally in different
> communities. Whereas in your vertical networks, most of your vertical
> networks are composed of organizations that serve the same community.
> This, in and of itself, offers another kind of challenge, because not
> only are you talking about different needs of different types of
> members, but you're talking about them serving the same community,
> which has, by it's very nature, more competitive issues associated
> with it than organizations that are not serving the same area.
>
> As we move into slide nine, we kind of go outside of the context of
> the healthcare area, that pillar, and recognize that collaboration can
> occur outside of the healthcare arena with other kinds of pillars of
> the community. In this particular instance we've got eight or nine
> "pillars of the community," from healthcare to insurance, to
> faith-based organizations, community-based organizations, educational
> organizations, business, environment, and public safety. Collaboration
> between pillars of the community, from our view, represents a
> tremendous potential for growth because, generally, when you
> collaborate between these pillars, the issue of competition is not
> present, because someone from a different pillar is bringing in a
> totally different kind of capacity or function that you need to
> success and hence, the issue of competition really doesn't enter the
> scenario, it's rather you're doing business in a better way for all
> parties involved.
>
> Just quickly, there's a lot of conversation and discussion about the
> emergence of relationships between healthcare providers and the
> faith-based community churches, mosques, synagogues, etc. Then these
> types of collaboration, and we've worked in one area quite extensively
> on along these lines, the element of collaboration between faith-based
> organizations and the healthcare organizations relates, again, to the
> specific functions of those organizations perform, and how, by
> bringing those functions together, you end up with a better product.
>
> The faith-based community in one group that we're working with,
> approximately 85% of the people in this community go to church once a
> week. That, by the very nature of people being in a church, at least
> once a week, the majority of the population, that church represents a
> real access point for information dissemination, and even access to
> healthcare services. So linkages and collaborations between healthcare
> agencies and faith-based agencies really can have a tremendously
> mutual benefit to both parties. The healthcare organization accesses
> more patients, and the faith-based community is increasing the health
> of its population and its overall well-being. In these instances,
> again, you get back to the context of benefits and how various
> participants get different types of benefits from participating in
> particular types of projects.
>
> Into slide ten. A much greater statement about the importance of
> multiple parties is present. Then when it comes to true collaboration
> the participation of independent agencies or different pillars, it's
> not only desirable, it's not something you want to see happen, but
> it's absolutely mandatory for a success. You can't accomplish what you
> want to accomplish without independent agencies at the table. The
> secondary correlate to that is that the participants have unique roles
> that only they can perform, and consequently they are all needed.
>
> Moving into slide 12. We take a look at how does goals, objectives,
> benefits, etc., etc., how does this all relate in some kind of an
> organized fashion? First of all, the goal of the network is that
> overriding share vision. The context and the key term here is shared.
> It's a vision that all members of the network or collaborative agree
> on, it's something they all want to see happen. It's very, very
> critical because when you come to those bumps in the road that always
> immerge, or when you go to competitive issues that immerge, the best
> way to do it in our experience is to get back to that statement of
> shared; why are people at the table together, and to revisit that
> concept and focus on what we're trying to accomplish. Then look at
> problems within the context of that shared vision; how are we going to
> get there, by working together, rather than spending a lot of time
> looking at a problem or a potential conflict. The issue is to get back
> to the commonality and go from the commonality to the solution, rather
> than go from the problem to the solution, from our view.
>
> The second context is objectives, that is how you get there, how you
> obtain the vision. Then, finally, the key constructed benefits, and
> that is the importance of the objective to each member of the network
> or collaborative.
>
> Moving into slide 13, and from our view this is real fundamental
> message that we have here, and that is an identification of the types
> of benefits that organizations can expect from participating in
> network programs. There are six that are listed, certainly there are a
> couple of more categories that could be added, but for means of
> discussion we like to look at benefits as number one. Facilities
> benefit by an improvement in the quality of care that they provide.
> Number two, the whole concept of financial viability is very, very
> central to our thinking in that any services that networks provide
> that contribute to the financial viability of their participating
> organizations are going to be valued extremely highly. Are you
> bringing additional revenue to them? Are you bringing economies of
> scale to them, which result in savings? These are questions that are
> important, and questions that we think need to be answered. All
> networks have to have a fundamental understanding of how they're
> impacting their members in these ways.
>
> A third area is market share. Will community health centers have a
> greater share of a market, of a community primary care market, as a
> result of participating in a project? The fourth area is stability.
> Does it provide a greater sense of stability of mission-critical
> functions? Does the community view this service as more permanent than
> perhaps it had in the past, and that's also related to the sixth
> concept of community image? Organizations participate in programs and
> objectives for a host of reasons. Some participate because it's good
> for their image over the long run.
>
> Finally, we have spirituality or wellness, which from our view really
> is the over-arching objective that some networks have, which is of the
> context of improving health status, improving the wellness of the
> community. A lot of networks have objectives or have goals that have
> those kind of connotations, and its good to have an understanding of
> which organizations in your network are really keyed into those types
> of benefits, because the extent to which people are keyed in to your
> programs and benefits really gives an idea of who's going to
> participate, who's going to really put some elbow grease into the
> program, and who isn't. Network members participate at different
> levels and different programs, and it's always good to have a
> fundamental sense of which hospital, which community health center,
> which public health department, which community organization is really
> going to get a benefit out of your program. From our view, those that
> get the greatest benefits are those that are going to participate to
> the highest degree, and then ultimately, are going to be very
> interested in sustaining the program so they continue to receive those
> benefits.
>
> As we move into slide 14, the key overriding concern is that to one
> extent the quality of care benefit is a given. One can make an
> argument that virtually any kind of improvement to an organization can
> result in improved quality of care, because regardless of what's
> effective, if it's purchasing things at a lower level, if it's finding
> coding personnel, it increases the overall climate for the
> organization, which is good for improving quality of care.
>
> I think a key message in all of this is the next point, which is that
> although less altruistic and politically correct, the other benefits,
> the financial benefits, the market-share benefits, and the stability
> benefits, really should not be under-valued. In many, many instances,
> what we find when we work with networks initially is there's a lot of
> comments about improvements of health status, or improvements of the
> strength of organizations, and the strength of the community, but very
> little that speaks to specifically what networks are doing for their
> members.
>
> In one sense, that hesitance may relate to kind of a political
> correctness of talking about altruistic things about community
> benefit, about reducing cancer rates, reducing cardiovascular disease
> rates, reducing hospital admission rates for asthma, rather than
> talking about the affects that the reduction of those rates have on
> member organizations. We like to think of it within the context of
> Maslow's hierarchy of benefits, it's a little play on the old Maslow's
> hierarchy of needs, that we think is a key point because it basically
> says that network leadership and members really need to recognize that
> in order to have these big community impacts, improving the health
> status of a community, there are other impacts that a network needs to
> have that gives its members the capacity to eventually impact on
> community health.
>
> Slide 15 has like level one in the Maslow hierarchy of needs was
> physiological needs, which are like food, air, and water, and those
> correspond to what we think are financial and market share needs. The
> next level up, once those needs are met, you look at needs like safety
> and stability, and then, finally, once those needs are all met, you
> can look at the context of community image and wellness. The key point
> here is on the bottom of slide 15, which is that you really can't
> reach this community wellness, community image, community well-being
> level, unless you've got financial security, market share, and some
> degree of stability. So we recognize that organizations have to
> receive those kinds of benefits, but those benefits are in fact
> enablers to greater objectives, or more altruistic objectives.
>
> All of these concepts are illustrated on slide 16, which shows the
> various levels, and the corresponding concept between needs and
> benefits. What we try and drive home here is the recognition that sure
> there are some very, very large community objectives in mind, in terms
> of improvement of access to services, health status, etc., but there
> are other types of objectives that need to be met that have to be
> recognized, that have to be a part of your thinking, in order to get
> to those levels. Here we see level one, two, and three, repeated, with
> corresponding needs and benefits.
>
> Lessons learned. Well what have we seen among networks over the last,
> again, 13 years, a fair amount of it network experience, which dates
> back to the early days of the Robert ..., basically a hospital
> collaborative project, which was started in, roughly around, 1988 or
> so, which was designed to try and bring hospitals to the table to work
> on common problems and come up with solutions they could all share. So
> we've got a legacy of about 14 or 15 years of experience.
>
> Well the first thing that we see is that it's never too early to
> identify benefits. Within the first two, three, to four months, one
> should have a good sense of how each organization expects to benefit
> from participation in the network. That is extremely important because
> as I referenced earlier, sometimes there's a lot of time spent on
> forming and storming, picking a name, picking a mission statement,
> getting some sense of what the members really want to accomplish. Our
> sense is too much time can be spent on those things, and to some
> degree they're self-limiting activities. You're going to spend as much
> time on them as you want to, in our sense the big issue is to get into
> the benefits delivery side of the equation as soon as possible,
> because that's the piece that's really going to make you viable over
> the long run.
>
> The second point is emphasis on process management. Process management
> is critical, there's no question, but when there's too much emphasis
> placed on the relationship building, emphasizing, and so forth, it can
> become a means to an end, a process in and of itself, and when it
> comes to getting financial support from organizations those are the
> most difficult types of things to find financial support for.
>
> The third point on slide 17, gets back to getting an understanding
> that, number one, you guys do have high process requirements, that's
> the fundamental nature of what you're involved in here. Multiple
> parties at the table means process requirements. The key view that we
> have though is that they're a means to an end, that you really,
> certainly, have to manage relationships, but you really have to manage
> them within the context of delivering benefits. This dynamic is huge
> on the field level of network management. It varies tremendously,
> depending upon the size of the network.
>
> Networks within the \$200,000, \$300,000 a year operational level have
> a real challenge, because the network leaders, the executive
> directors, really have to balance a tremendous amount between managing
> the relationships in the network, and actually delivering benefits.
> You have to be involved in both of those activities, and that's
> difficult because managing relationships alone can take all of your
> time, but you really have to have a handle on getting those benefits
> out to your members.
>
> In larger organizations, you know half a million, million, two million
> dollar a year organizations, the network executive director is
> primarily managing relationships, that's primarily the function and
> the responsibility. So in networks that are funded at lower levels,
> it's a much more difficult challenge for leadership, because you not
> only have to manage the relationship, but also really focus on your
> own energies on delivering benefits. The key point there is that we
> think that benefits build relationships rather than vice versa.
>
> As you move into slide 18 we've got the yin and yang of process and
> benefit, and you really have to have a balance there. You can't
> overemphasize in one area, they have to be done in tandem, if they're
> not they're out of whack. I think over time you're going to find a
> little more emphasis on process at one point than benefit, but over a
> year's period of time or so you should see this kind of a balance in
> place.
>
> Moving into slide 19, how do you do that? You need to formally report
> on your work plan each quarter, talk about this with your members,
> talk about what you're attaining, talk about the number of people that
> you serve, talk about the number of people you've trained, talk about
> the number of programs that you've reviewed, talk about the number of
> memorandums of agreement that you're exploring, talk about the
> financial pro forma's that you reviewed. In detail, really go through
> the kinds of progress that you've made each quarter as a laundry list,
> as a way of keeping people on track.
>
> Specifically look at how far you've gotten towards some particular
> expected benefit, and recognizing that an expected benefit of let's
> say increasing revenue to a group of providers via the increased
> number of people enrolled in insurance programs is something that may
> take a longer period of time to accomplish, but nevertheless, always
> keep your eye on the ball, so to speak, if the objective is to enroll
> three or four hundred additional people that previously had no form of
> insurance into some form of program, you need to look at reporting on
> those numbers, even though the results may be relatively small at the
> get go.
>
> Within that same context, it's always good to translate those numbers
> into some kind of impact for members, and I think a little further in
> the presentation we note that every new person that comes into some
> kind of insurance coverage, in a given community, will bring in about
> \$4,000 of revenue to participating agencies for services. So when it
> comes to benefits ... programs that are addressing those types of
> issues, not only increase access of services, but also are
> strengthening the financial viability of the providers in the network.
>
> The final point there is to reassess member interests and potential
> new member benefits. In the collaborative scenario, in the network
> scenario, you're in the healthcare scenario, number one, and that's
> ever changing, and that what might be a critical issue today may not
> be tomorrow, and it's good to formally go through these aspects every
> six months or so, because, number one, they help you keep on track,
> and, number two, it may point to something that really is immerging in
> the community that only the network is well-positioned to address.
> Opportunistic activities from our view are essential as change agents.
>
> At this point I'd like to open it up to our panel members and have
> something to drink.

B. Davis Well I have a number of comments from both my experience at
running a network and working with networks. Just on this last slide,
19, if you look at this slide, really what this says is we're in
business. Often times networks that I work with, especially networks
that have received grants, the members think, "Oh boy, this is free
money, we're going to do something...," and not until about two years
into the program do they realize, "We're really in a business here, and
how are we going to sustain this business?"

If you look at this, our work plan, report on each quarter, what kind of
progress are we making, what are the benefits, and are these benefits
something that our members see as something work sustaining over the
long term; that's just one insight. Another is that often times I see
networks, they'll start out and they'll focused on a particular program,
and that program becomes all-consuming for the staff, and what happens
is that staff then gets totally sucks into the program and gets managing
the program, and they don't have the resources or the time to really go
back and reassess member interest, and the members might be interested
in that particular program, but in my experience, once a program's
running and they're receiving benefits, a lot of times members are
looking for, "What are you doing now?" Or "Here's a new issue that I'm
facing, or a new challenge, can you help us with that?" Often times the
staff for the network doesn't have the resources to do it.

I think in terms of reassessing member interest I also think you have to
take and formally reassess the scope and the resources internally to the
network to be able to respond to member needs. A lot of times network
boards don't really think about that, they only think about what the
benefit is to them, and they lose sight of the fact that they need to
invest in this business in order to get more out of the business. So
that's one thing that sort of struck me. I have other comments on other
slides; I don't want to totally dominate the discussion here. So it's
kind of up to you folks if you want a couple more comments, and then
I'll be quiet here.

G. Bonk Catherine, Curtis, Margaret, anything to add?

M. Jackson I can't say anything as eloquently as Mr. Bonk does, but I
can serve as an Exhibit A of how we've accomplished some of the things.
We started with a list of what our member organizations needed and
wanted, without regard for whether there was or was not a network. That
was a simpler thought process. If a CEO could pull out his list of the
five most important things for his organization to achieve in the coming
year, network or no network, and all the network members did that, it
was very easy to arrive at where is the intersecting set of things that
will benefit from network effort.

Buzz's comment, I think, is very comment. I've had some learning to do
with regard to in a new operation it's very important to do things
right, but if we don't enough staff that are detail-oriented and able to
do things right, or if we don't have enough staff who are able to do the
right things, on a flexible basis, then we skew ourselves, and as Buzz
said, it becomes very difficult to serve the evolving needs of our
organization.

I'd liken it to a personnel function in a large hospital, some of it is
a matter or immaculate record keeping, but if that's all there is, then
all the steps you go in with opportunities and being sure that the
benefits program reward the outcomes that we want are missed; so that's
been crucial for us to try to get that right balance.

G. Bonk Hearing no other comments at this point, why don't we move
along, because it's already about 3:20. Into phase two, and, hopefully,
I can convey some more detail on this whole idea of interest and
benefits and identifying them and the whole issue of fast-tracking
development.

As we move through slide 20 into 21. The concept of mapping member
interests and benefits, there's three elements to it. The first one is
to identify or reaffirm your core participants, and a key aspect of
identifying who really wants to be involved and at what levels pertains
to what, we use the term compelling needs, that the network is
addressing, so we'll talk a little bit about compelling needs.
Compelling needs are basically needs that an organization has to do
something about, it can't ignore them, they're that critical that it
really has to act on them.

> Secondarily, we look at the idea of identifying and sharing the
> expectations of each network members, relative to benefits, what do
> they expect to get out of this? It's very important, but it's also
> difficult because it's subtle, to talk about how each member is really
> going to benefit from participating. I think there's a natural
> hesitancy to not talk about members in that light because, from my own
> perspective, there's a certain degree of discomfort when you say,
> "Well, St. Mary's Hospital expects to do 50 more heart transplants as
> a result of a strong linkage in continuity of care program that's
> being developed with community health centers, community
> practitioners, and public health departments."
>
> It's kind of tough to speak in those terms, but we think it's really
> important because, number one, it again gives people a good idea of
> what the expectations are, and what some of the benefits are, and it
> also tends to bring people more into the circle of the fact that they,
> in their organizations, are really going to benefit from what's going
> on here, rather than just the philosophical, politically correctness
> of collaboration and working together.

Moving to slide 22, is an example of how a particular networks members
differ, and what they think is important about the network. Now the bulk
of examples I'm going to be talking about from here on out are the
vertical networks, and that is the networks made up of different types
of providers that are generally serving the same community, the same
service area. In some cases one might think of them as potential members
or candidates for an integrated delivery system. Our view is that
they're viewed that way because in effect they are different
organizations, all of whom have a role in continuity of care, and all of
whom may potentially impact on a particular individual during their
course of treatment.

The distinction here, again, is that these are vertical networks,
different kinds of interests, different types of cultures in these
organizations. As one moves towards change, one needs to take it into
account, and also recognize it's a more difficult kind of network to
operate, from our view, than organizations of the same type.

Horizontal networks have a different set of challenges. In this instance
we're talking about the vertical network, and I think there are a fair
number of vertical networks through the network development program. But
what we have here are a list of members, St. Mary's Hospital, the
Regional Health System, County Public Health, Emergency Medical
Services, Fire Department, Emergency Communication, an additional
hospital, Social Services or Social District, Social Welfare Department,
and a community action organization called New Beginnings. Those are the
members of the network, all are pretty much different, other than the
hospitals, but size and service and scope they're very different.

This network is addressing five different kinds of objectives. One
pertains to an overall needs assessment of what's going on in the
county, what are health status needs, what are the service access needs?
A second objective pertains to a need to develop, potentially, some kind
of shared services. A third objective relates to a need to improve on
the emergency medical service system capacity in this particular
community. A fourth pertains to quality improvement initiatives designed
towards risk management. A fifth objective pertains to Medicaid managed
care. The numbers on the chart relate to the expressed priority of each
organization for each of these different programs.

> When we look at St. Mary's Hospital, it says, number one, it thinks
> that the needs assessment was very important, number two, it thinks
> that the shared service OPD is an important program, and number three,
> the EMS system is an important program. Notice it doesn't think the
> quality improvement or Medicaid managed care operated by this network,
> are things that are very important to it. What does this mean? It
> means that when it comes to the five programs that are offered, the
> hospital really only cares about three of them, and those are the
> kinds of programs that you could expect some level of participation
> from the hospital. That one was from St. Mary's. Don't expect them to
> be involved in quality improvement or Medicaid managed care.
>
> The regional hospital has the same interested needs in shared
> services, but is looking at the quality improvement risk management
> services as something that it wants to be involved in. The Public
> Health Department looks at needs assessment as important, the EMS
> system as second in it's ranking, and then, finally, Medicaid managed
> care as critical. The remaining members have different priorities for
> different programs. Basically, what we're showing here is that when it
> comes to the needs assessment, the two hospitals plus the County
> Public Health Department are the ones that are really interested in
> that, and want to support it, and want to see it occur.
>
> When it comes to shared service operation, you have the two facilities
> that are very interested in involving themselves in this, but then
> when you get to the EMS system you find a different set of priorities
> for different types of participants, and, clearly, the Fire
> Departments, EMS, and anybody involved in Emergency Services thinks
> this is a program they really want to be involved in. So you don't
> expect them to be excited over needs ... shared services or Medicaid
> managed care. Conversely, as we move way down the chart, we look at
> Pittcon County Social Welfare and New Beginnings, they think that the
> Medicaid managed care program is something they definitely want the
> network to be operational in because there's some sense that the
> managed care entity may, in some ways, affect patterns of care, and
> they're concerned about that, and they want to make sure that existing
> level cares, at a minimum, are being maintained.
>
> Once again, we see a different level of interest, by member, and so,
> once again, if you've got ten organizations at the table, and they're
> all relatively different types, don't expect them all to be interested
> in all of your objectives to the same level. Those objectives that
> pertain more to their core services and functions are the ones they're
> going to be involved in. Don't spend a lot of time trying to convince
> them to get involved in the other activities. Spend your time on
> delivering benefits in those programs that they are already interested
> in.
>
> As we move into slide 23, we get into the issue of benefits
> assessment, how important are benefits, and what are types of
> benefits? To me this is a good point that illustrates how differently
> organizations are going to perceive benefits from different types of
> programs, and they need to know that. Here we take the regional health
> system as an example, in slide 23, and here we list four programs at
> the top. We don't put Medicare managed care in there because it's not
> at all important to this organization, so why bother to put it in
> there, forget about it. But as we look at these various benefits, and
> we look at needs assessment, well why does a regional health system
> want a needs assessment in a county that's 60 miles away? It's unusual
> because we've got spirituality or wellness ranked number one, what's
> that all about?
>
> Well, it's all about the fact that in this particular state, all
> facilities, all hospitals, are required to develop something now in
> it's hospital community service plans, and the extent to which these
> plans identify unmet needs or immerging needs in the market, is a good
> aspect of the plan, that's something that the plans are asked to
> address. When it comes to this market, this facility is interested in
> expanding its influence in this market, and think of it as a part of
> its service area, so a completed needs assessment, although it seems
> to be a minimal impact kind of activity, in this particular instance,
> is viewed to be the biggest benefit that this organization can get out
> of participating.
>
> Then we look at the ranking of the other benefits. The second one is
> market share, it sees that through the needs assessment its going to
> get some sense of, perhaps, unmet need or demand, and, also,
> potentially get a sense on what its own market share position is for a
> variety of services. So, hence, it thinks that's important, and that
> ranks two. Stability, receives a three, a four, and the contacts tiers
> that it will have an understanding of where it fits within a market
> place with other organizations that may help for it understand its
> stability needs in that area as a service provider.
>
> Finally, the needs assessment has the most minimal financial viability
> impact of all. It's not going affect their bottom line, but what it
> does is it affects other aspects that are important to them and to the
> future of the facility. As we move down the list, we see again a
> differential value placed on different types of benefits. The shared
> outpatient department, they're looking for market share, they want to
> increase market share here.
>
> This increase in market share also relates to an increase of stability
> or presence in the market, which is something they're seeking. So
> that's something that's also very good. Financial viability, I'm sure
> there'd be some arguments about this, but in some instances,
> facilities and hospitals generally think that outpatient services are
> lost leaders. They lose money by getting into this market. It depends
> on volume, obviously, it depends on payment rates, but in some
> instances facilities don't want to get into outpatient services
> because they think they're a deficit operation. So that ranks three
> out of four.
>
> Then, finally, the spirituality or wellness dimension is relatively
> the least important when it comes to shared OPD. But as you can see,
> there's a different level of importance for different programs for
> this organization. What does it mean? It means it wants to participate
> in a needs assessment, although that's not a big impact program, but
> it is in terms of a particular area that the hospital is interested.
> Secondarily, the shared outpatient is something it wants to be in
> because it really is looking for increasing market share, not
> necessarily in that outpatient department, per say, but in the
> regional and tertiary services that are offered at that facility.
>
> Page 24, the big question, benefits beyond getting a grant. My sense
> is that all of the grants really have identified some objectives that
> the members have signed on to and are interested in pursuing, but we
> all know the adage, "The good news is that you got the grant, and the
> bad news is that you got the grant." Certainly it's a tremendous boost
> to any community to receive funding, certainly of the level of the
> network development grants, \$200,000 a year for three years, that's a
> very good level of funding. I think communities and organizations that
> secure them automatically have a sense of pride, and should have a
> sense of pride. The problem is, now you've got to do something for the
> money. As we all know, it's one thing to think about what you want to
> have happen, but the next issue is that when you get the funds that
> you thought you needed to get it done, well now you really have to
> make it happen. Now the real relevancy of the network objectives
> becomes the key issue to the survival and the stability of the network
> program.
>
> Here what all organizations need to do, and they almost need to do
> this, regardless of the level of involvement of participants in a
> grant, as soon as you get the grant, reassess your member's
> priorities. Put those four or five objectives out there in front of
> your membership and put them up for a vote, which are real critical at
> this point? It may be six to nine months since the grant was written,
> and situations have probably changed, and some things that were
> priorities nine months ago may no longer be priorities. So regardless
> of the level to use sense of commitment, it's good to assess member's
> priorities within the first month or two of a grant award.
>
> The second piece is that once you get a sense of priorities, an extent
> to which they remain the same or change, is to relate your members
> priorities to your grants objectives. If the grant objectives are to
> reduce the level of uninsured in the community, then it's good to look
> at that within the context sure of improved health status through
> greater aspects to services. But also that by the enrollment of one
> person of an insurance program wasn't previously enrolled can bring
> \$4,000 to service providers in the area. To track those kinds of
> relationships for your members and to show them how they may think
> that an objective may not really relate to their priorities, but point
> of fact, when you look at what they're really looking for, enhanced
> revenue, and a larger pool of paying customers, those two are very
> sympathetic, very similar kinds of objectives. The issue is you got to
> make the translation, you've got to walk them through it.
>
> Finally, if the relationship is minimal between what your networks
> priorities are and what your member's are, then consider adjustment.
> We all live in a highly dynamic environment, and the compelling need
> concept assumes that there's a reason why organizations really have to
> work together because there's a big, big problem out there. If that
> problem's no longer around, adjust your objectives, take a look at
> things that do relate to where your priorities had been, but are more
> basic to your network and community needs at this point.
>
> The mapping of interest and benefits helps you to get a fix on where
> people are at, and it's also like a little sheet that you keep in your
> drawer, and as you're moving through a year, or through a couple of
> months, it's good to just pull it out and review it and say, "Well,
> okay, St. Mary's Hospital we expected them to be involved in this, and
> we expected them to get benefits out of this, but where are they right
> now? Have they been showing up at meetings? Have they been doing the
> types of things that the work program calls for? Has the Chief
> Executive Officer called the Information Technology Officer and told
> the Information Technology to sit down with the Network Coordinator
> Information Technology person to discuss the current software and
> hardware capacities of that particular institution?" Track them like
> that; track them back to the expected actions of these organizations.
>
> The benefit map shows the type of motivation, and it's that
> preliminary self-inability check that really gives you a sense of how
> your network will survive, and what are the most likely ways in which
> you're going to be sustainable, beyond a grant year. The key element
> to tracking is to really try and relate, virtually everything you do
> to some kind of financial impact. It may seem harsh, it may seem too
> cold, it may seem too money-like, but the more that you can draw a
> relationship between your objectives, what you're accomplishing, and
> how it's going to strengthen the financial core of the community for
> service provision, the better off you are.
>
> As we move to slide 26, now we're getting into a view of what this
> little piece of software is all about, and it runs on Microsoft Excel.
> It has on the first screen we see there, on slide 26, it's called
> member and program names. It's very easy to operate, very simple to
> use, you should have it on your computers now because it was e-mailed
> to you. Just open it in Microsoft Excel, and the first spreadsheet
> lists member and program names, and that's kind of at the bottom of
> the page there, it says ... member and program names. What you do
> here, and the ones that you have, have a bunch of blanks of them, or a
> bunch of zeros, you just enter the name of each member in that member
> column below, just type it right in there, the first one's St. Mary's,
> the second, etc., etc.
>
> Then on the next column over you enter the types of programs that
> you're pursuing, and you center them right down in a row. The first
> one's ER in this instance, the second was access to care, third one is
> conditioned of the neighborhood, the fourth is substance abuse, and
> the fifth is community wellness.
>
> Once you do that, as we move into the next slide, what happens is that
> the programs that your network offers are automatically displayed in
> what's known as row eight, as we look at the screen now, inappropriate
> ER use, access to primary care, condition of the neighborhood,
> substance abuse, and community wellness. Whatever you've entered in
> the previous spreadsheet, now appears on this tab, and it lists your
> program. Coincidentally, all of the members that you've listed now
> appear going down column B, St. Mary's Hospital, community concern,
> etc., etc.
>
> Now the next part is the part that either you can do yourself, and
> actually it's probably a good idea to do it two ways, look at all of
> your programs, look at all of your members, and then you assign a
> value to what you think that member's interest is in the various
> programs you offer. Like, in this instance, we've got St. Mary's
> Hospital, you rate the programs from one to five, with one being a
> high priority, and five the lowest. In this particular example we're
> looking at ER use as being a real big interest, access to primary care
> also important, the condition of the neighborhood not important, and
> we'll talk about condition of the neighborhood. We're talking about,
> unfortunately in this instance this is an urban scenario, but it could
> occur in rural communities and places that the housing conditions are
> very poor, there's a lot of broken glass, a lot of dangerous
> environmental circumstances in the area, bad lighting, those types of
> things, but here, clearly, the hospital is least interested in the
> condition of the neighborhood.
>
> Basically, you yourself should do this, and you should rate what you
> think people are interested in, that's point A. Point B is then have
> each member themselves identify what they're interested in, what
> they're priority level is, and then compare the two. Clearly, their
> view of what's important to them is more important than your view of
> what's important to them, I want to restate that. The issue here is
> their perception of what's important, not yours, because they're going
> to act on what they think is important, not on what you think is
> important. If you're trying to change behavior, and you're trying to
> shift viewpoints of what's important and what's not important, and
> some networks are trying to do that, recognize you're in a much, much
> longer timeframe, you're on an educational time track, and if you're
> doing those types of things, look at three to five year horizons for
> any kind of impact.
>
> So, once again, the big issue is, "What do they think is important?" I
> suggest you do it because it's a good way of getting your own sense of
> how in synch you are with your members. I'll give you an example in
> which we did this with a group, not too long ago, and we were totally
> out of synch, I repeat, totally out of synch with where this group was
> versus where we thought they were.
>
> As we move into slide 28, what you have here is then you get into a
> ranking of benefits by member. The member actually appears at the top,
> St. Mary's Hospital, and then we have the expected benefits, and here,
> it's worthwhile if the organization itself can rate it's expected
> benefit from each program, and then below that, this one is an area
> where they can potentially identify the types of services that they
> bring to the table to help you to accomplish your objective, the kind
> of issue that Buzz and Margaret were talking about earlier, where not
> only do you have to have a good sense of where your members are and
> what their needs are, but you also have to have a pretty good sense of
> what they can bring to the table to help move things along.
>
> Adjusting your objective, ever changing your objectives, have to be
> relevant. If membership is waning, if nobody's showing up at meetings,
> redo a reassessment, and you may want to get into the whole context of
> really taking a look at collaborative potential, as illustrated in
> slide 30.
>
> Here we have approximately 60 or so programs or services that networks
> can offer. The attempt here is to kind of provide the menu of services
> that network collaboratives can offer, to describe the status of
> activities in some sense, but then also to give people the idea of,
> "Gee, how much more is out there? Gee, the information technology
> program is a bust, we can't even get a reasonable Internet service
> provider out here to last more than six months, every time we turn
> around somebody's gone, so how can we really establish anything like
> that?" Well, in those instances, clearly, you're bound by the
> environment in which you operate, and to the extent to which you're
> going to expand some Internet capacity is probably limited.
>
> It's a business development issue, economic development issue in the
> community, and you're behind the curve on that one. But that doesn't
> mean you should throw the objective out totally. Our sense is you
> should sidetrack it, it's a good idea, it's an important idea, you
> can't do it right now, but what do you really want to move on, what
> are other things you can address?
>
> So here you could share this list with your members and have them
> identify, of all of these services which ones they think are something
> that they need, and something that they think can be developed or
> conducted from a network orientation. We split them up between
> supporting roles, where networks serve kind of back office
> administrative service functions, and there's about 30 of those,
> 24-hour back-up, balance scorecard development, clinic management,
> regional partnerships, risk management, etc., and then there's some
> operational roles that networks can perform, information referral is a
> big one, patient member services to some extent, coordination of
> preventive healthcare services - I don't know if we have enrollment,
> well we have enrollment in a different category -- pharmacy, durable
> medical equipment, etc., there are some operational functions that may
> be that the network may be a good home for.
>
> Community access is a big one, particularly with vertical networks
> because here we're talking about increasing an individual's ability to
> access multiple programs, and that is, from our point of view, a
> fundamental and reasonably distinct role for a collaborative or a
> network. Be an ombudsman, a one stop access center, be a storyteller,
> a community encourager, and then, ultimately, potentially, some
> economic development areas.
>
> Fast tracking, how do you get there from here? Slide 31. You can do
> three things quickly: a capacity assessment, a best practice
> assessment, develop your actions plans, and then do this within a
> three to five month period of time. Get a sense of capacity of members
> and what they want to do. Get a sense of best practices as they relate
> to what you're trying to accomplish in terms of relevant models. Then
> I take from those analysis what members can do, where things need to
> go, and identify what's relevant for your communities, big, big,
> issue.
>
> As networks start to implement their programs, in some instances,
> you're going to take a program that was successful somewhere else and
> assume it's going to be successful in your community. That may or may
> not be correct. The extent to which your community and the community
> that it was function in are similar is a key determinant of whether or
> not it's going to be successful. Then you look at specific roles or
> members, your action plans, and ultimately your program benefits.
>
> What can members bring to the table? Slide 33. They can bring
> personnel, programs, facilities, technology, access to special
> populations. As you look at best practice assessments, on 34, you need
> to look at program-specific issues, a particular programs. If you want
> to do a lay worker program, examine lay worker programs, find out what
> the dynamics are, talk with other collaboratives, but make sure that
> what you're looking at relates to your community. A lot of lay worker
> programs are access points to centralized closed systems, a set of
> providers. It's very different than creating a lay worker program from
> a whole bunch of organizations that are vertical network.
>
> Look at literature, and certainly rely on your federal technical
> assistance programs as great sources of help. Relevancy, slide 25.
> Number one, make sure it's a rural model. Rural is not small urban.
> It's different, it's not small urban, there are a whole other set of
> dynamics that influence implementation capacity, other than sheer
> size. Resources, capacities are vastly different, and it's not simply
> a matter of how much, or how big the population is, it's a question of
> the nature of the real community and it's needs. Look at the kind of
> network you have, cultural sensitivity is a big one, are you
> developing programs that relate to the target market? What are the
> resources? What can you learn in terms of operational issues, and
> things that have gone before, etc.?
>
> Select the most relevant model, the program that means the most sense
> to you, the one that relates to you as you see it, shape it to local
> conditions, and then build and design only when circumstances warrant.
> In other words borrow, borrow as much as you can because to build and
> design costs time and money.
>
> There's a real quick way you can do these capacity assessments or fast
> track assessments. You can do them through the Internet, and very
> quickly, or you can do them hardcopy. They're very simple. Slide 37,
> what's your organizations priorities; that's number one. Number two,
> how do they pertain to the special needs in the community?
>
> Number three, you take your objectives for your network, list them,
> and ask them to rank them. We've seen the results of that type of
> thing. Number four, what kind of resources or tools do they bring to
> the community? That's the additional question you can ask. These are
> not labor-intensive activities, and they provide you with the
> essential information needed to move forward.
>
> As I mentioned, it's good to do this assessment of where you think
> organizations are at and compare it to your own, as we look at slide
> 39, just to get to the heart of the matter. This is a very large task
> force, coalition, and 45 different organizations. We thought the hot
> button for this group was inappropriate ER use. As it turns out, it
> wasn't. It was the least important objective of the five that this
> group was looking at.
>
> This chart illustrates the outcome of this little assessment that we
> did earlier, in which each member ranked all of these various
> programs. The bottom line is that appropriate ER use came out the
> least important, whereas wellness came out the most important.
>
> As you move to slide 40. The key here is slide 40 shows the different
> types of organizations that were involved in the assessment, and how
> they responded differentially to the different kinds of objectives
> that you had in mind. The ER use piece, as we see it, the
> organizations that were most interested in it were the payers and the
> healthcare service providers, the hospitals, they thought it was
> important, as you see those are the longest bars for inappropriate ER
> use, whereas the other members, which really made up the majority of
> membership or the organization thought it was less important.
>
> Consequently, as you move down toward the wellness area you'll also
> see the same phenomenon in place there. You find the payers and the
> hospitals were less concerned about the ER phenomenon, then the
> community organizations. As you move through that assessment then you
> get into your action plan development, sit down with the interest
> members, discuss the models, revise them as they see their roles, and
> then act.
>
> Now I'd like to turn to the other members of the panel and really try
> and speed things up here. Buzz, Margaret, Claudia?

B. Davis I have a couple of comments. Slide 23 ...

G. Bonk That's the member benefits by type?

B. Davis Yes. Just one, as you're assessing your members expectations
and benefits, often times that means you might be talking to more than
one person within each of your member organizations depending on the
type of program it is. Sometimes I see new network directors assuming
that because a CEO who sits on their board said that this is really
important, they assume that that's where the final decision is going to
get made. Often times on programs I find those decisions might be made
by the Chief Financial Officer or some clinical person. So it's
important that you figure out who is that CEO going to turn to, or who's
going to be on the front line that going to make a decision between
reporting that particular program, and truly understanding the benefit,
and buying in to that benefit, and ultimately, those people who ought to
have a lot of influence whether to participate or to support the
program.

So a word of caution there that as you do these assessments you want to
make sure that you're talking with the person who's ultimately going to
have the final call.

G. Bonk Great point, by the way.

B. Davis Then just one comment on the last few slides in terms of fast
tracking the process. What I found is that a lot of times networks only
have one or two staff people, and as they start to fast track they get a
little overwhelmed because how are they going to make all of these
calls, how are they going to connect with all of these people?

One of the things that I found is a pretty successful process to use is
called a workout session. It was really something developed by AT&T and
General Electric ten or 12 years ago, which they still use, and it's
where you bring together the key stakeholders around an issue. Say you
want to start a program for the uninsured, or you're in a horizontal
network and you want to start a staffing agency or a risk management
program, you bring the appropriate people together, you identify some of
the key questions for them to address, and then have them actually work
through a process for a couple of days. Then, at the end, they make a
recommendation to proceed with their action plan and a timeline, which
is usually three months to six months to complete it, and they actually
present it to the board for a thumbs up/thumbs down.

I found that that's sort of a very efficient way to engage a lot of
stakeholders in a very short period of time, especially if you don't
have a lot of staff. Those are just a couple of comments there.

M. Jackson This is not as efficient of a method, but what's been the
most successful for us in Vermillion Parish is to, in terms of finding
out who really cares about what, we've embarked on things from time to
time that we found it good, and people were happy enough to raise their
hands to express interest. But when the work plan was out there that if
we're going to do this these are the steps we need to follow, it's easy
to conclude that if no one follows any of those steps, you have an
answer. Instead of excruciating about that or wasting time with it, we
found that if you put it out there and the response doesn't come, then
move on to something else and be happy that you've answered the question
in a way that couldn't be any more clear than that. It doesn't send very
fancy of a method to do it, but it's been our most successful. If you're
trying to know who to ask in an organization, sometimes it can be very
time consuming to figure that out, and it can be different people for
different issues.

So we just put it out there, it's like have a party and if nobody comes
then you know it wasn't a good idea, so you move onto something else.

Also, in terms of being able to make presentations, one of our member
organizations fiscal year has just ended. So one of the things that we
had the privilege of doing was creating a bullet point to express to the
organizations board what that organizations cash outlay for Vermillion
Community Health Network That's very to the point, so we added up all
the cash that had been put into the network effort, which was \$10,147,
and then we added up all of the things that had demonstrable specific
clear financial value to the organization, and given that part of its
mission was to bring pharmaceuticals in for people who couldn't afford
them, the actual dollar income was \$165,134.

> So what that translates into for the board member organization is they
> spent a dollar, for every dollar they spent, in effect they got back
> \$14. So I think that their openness to exploring more things that
> could be done through the network will be greatly enhanced in the
> coming year. So if any of you want to spend a dollar and hope to get
> back \$14, we'll try to do it for you. Was that funny?

G. Bonk It was the magic. I'm going to just quickly go through the phase
three piece in about a minute and a half, and then open the call up for
all questions. I apologize, I hoped to have got through this a lot
faster, but it seems to have a life of its own at times.

Very quickly, I think, when we look at the phase three aspects, and you
can all review these at your leisure. There's some real concrete tips on
what do you do when this happens, what do you do when people are
fighting, what are do when people don't have an interest, how do you get
network people to cooperate when they don't want to, what happens when
the two big power people at the table are in conflict and tainting the
whole process? I think they're all pretty much explanatory. I think at
various stages of networks you're probably all going to encounter all of
this stuff. I think they're all pretty much self-explanatory in terms of
the material that's referenced here.

The only issue I just want to reference is the big question of how do
you talk about financial support from your members? To me, that's a
square one issue, it's always a problem, it's a big problem for network
executive directors for staff, because in a sense there's this issue of
the member's wanting something, and to actually say they have to pay for
it is a very delicate, difficult issue to address. Our sense is the best
way to do that is get into the discussion of benefits at the get-go, and
self-sustainability at the get-go, and have that concept of really
making this thing last a part of your mantra, so to speak, in dealing
with your members and always bring that to task to some degree in all of
your meetings.

Secondarily, when you're really far down the road in your third year, if
you don't have anything that you're doing that contributes to financial
benefits, I would say close your door for two or three days, take a hard
look at what you can develop over a relatively short period of time, and
devote all of your energies to it. Because to demonstrate that is so
critical, and it's so critical in our estimation that you really need to
put aside other things that may have been effective but are just plain
non-sustainable.

At that, I'd like to open the call to anyone's who's still listening.
Thank you all for dialing in at this point.

Coordinator At this time, I show no questions.

C. Lacson I want to thank Greg for an incredible presentation.
Everybody, as I heard from Rebecca, this was of that the sessions that
was found to be one of the most practical sessions during the October
Health Policies meeting in D.C. in September. If there are any questions
after the end of the call for Greg, Greg is your information in the
e-mail that Rebecca sent?

G. Bonk Sure. You can reach me at 716-688-8448, or <ConsultHMS@aol.com>.

Coordinator We do have a question at this time if you'd like to take it?

G. Bonk Sure.

Coordinator Allison Hughes you may ask your question.

A. Hughes This is very productive. I enjoyed it, thank you very much. I
did want to ask this question; there is a group in my state that is
trying to form a network of about 24 different agencies: social service,
hospital, clinic, name it, county health department; can it work?

G. Bonk Sure. The essence of these very complicated vertical networks is
some identification of objectives. That's the square one question. Once
one identifies the compelling or critical issues in a community, then
it's a question of identifying how you can address those programs
specifically, or those objectives specifically, and what roles do those
various organizations want to take in terms of being a part of a
solution.

As I referenced, it's unusual, 90% of our business is in rural
communities, but we're working in one group that has 45 different
members from municipal housing authority personnel, to community health
centers, to regional hospitals, to small hospitals, to health
departments, to mental health departments, to civil action
organizations, to community groups, to block groups, to alliances, I
mean it is virtually everything in the whole world. The issue that we
have been looking at is how do each of those various groups contribute
to a successful solution, and in a lot of ways they do and they're very
complimentary.

The key is, though, again, well what are you trying to accomplish
through collaborative action? Then, well why do you need various types
of resources and capacities to accomplish what you want?

A. Hughes What about virtual networks?

G. Bonk Sure. We didn't talk about the issue of centralized versus
de-centralized capacities, which to some degree is an extension of
virtual networks. In the constructive, no matter how you're designed,
how you're structured, whether or not it's a network with a half a
million dollars that hires all the staff and does all the work, or it's
a network with a half a million dollars that has staff of various member
organizations performing various services for the network as a whole. Or
it's virtual, organizations participate to the extent to which they
bring capacities to the table, and it's done through a very little
bricks and mortar kind of aspect to it.

All of those different structures really related to what you want to
accomplish and how it's best to accomplish it.

Coordinator Our next question is from Lois McCarry. You may ask your
question.

L. McCarry Actually, I didn't have a specific question right now, and
you answered part of it right while I was signing on, but I didn't want
to leave the session without complimenting the speakers and the panel.
Just because there were no questions I don't think that means that we
didn't find it very valuable. There's a lot here to absorb. I see how it
relates extremely well to some of the issues we've faced, and we can
identify with what you're talking about.

My question I came up with as I was signing on to compliment you for
your excellent format and presentation you answered by giving your phone
number. Thank you very much.

Coordinator Our last question comes from Cathy Cook. You may ask your
question.

C. Cook I just want to also compliment you on the presentation. It was
very valuable information. One of the comments or questions I have for
the panel is we are a horizontal network of community mental health
centers in the state of Indiana. Do you suggest becoming a vertical one
to be more sustainable?

G. Bonk First of all, and I'd be happy if Buzz would join in on this
because I think he has more experience than I do when it comes to the
operation of horizontal networks. As a horizontal network, it seems to
me that you're in a position where you can charge fees for services that
all members use, and that is a potential road to sustainability.

As you become more diversified, you diversify your membership, in my
view, unless you are bringing into your network a financial capacity,
you may be diluting your efforts for sustainability. Bringing in payers
from the context of a vertical network is, as far as we're concerned,
one great way to look at self-sustainability, particularly when you're
talking about wellness programs because here you are having an impact on
their bottom lines. So in conversations we've had with large networks
that have payers in it, I've been shocked that they haven't just thrown
their hands up in the air and say, "Absolutely not, you're not getting
any money from us." They haven't done that. As a matter of fact they've
been more than interested in looking at it.

So the initial reaction is it seems to me the horizontals because you
get the same kind of organizations and can become kind of a support
resource for them, represent a good target for dues and fees, as you
become more diversified, unless you're bringing people in that have
resources that are going to sustain programs, it may become more
difficult. But it depends on what you're going after, and what you want
to do. Buzz?

B. Davis I think certainly the most important question is what are you
trying to accomplish? If what you're trying to accomplish is an
alignment with your particular kind of member, then horizontal network
is probably going to be much easier to work with. However, if you're
working on a particular program that you think, "Well, gee, if we could
bring in some of these other players from the community, it would
strengthen our program." There are lots of different ways of striking a
relationship with them without making them members. You might want to
partner with them, for example, on a program.

> Typically, networks, especially horizontal networks, over time
> continue to develop and address different problems and issues. If you
> were to diversify your membership it really sometimes puts some pretty
> tough boundaries around being able to explore a lot of different
> programs. You start to go to the least common denominator for all of
> your members, and that makes it tough.

I would have to agree with Greg that staying a horizontal network, with
a similar type of member, is certainly something that I would want to
explore and sort of turn over every rock, look at every possibility
before I started extending my membership.

That's kind of a quick answer to a very complicated question that you
really need to have a little more information about what you're trying
to accomplish.

C. Cook That makes all good sense.

Coordinator There are no further questions at this time.

G. Bonk Thanks a lot, everybody.

C. Lacson Thank you, Greg.