Computerizing for the future: the Frontier Group's TOMIS.

How and why this multi-faceted post-acute care provider customized its IMS 

We're at a crossroads in long-term care. Just as our caregiving organizations are becoming broader in scope and more complicated in offering various levels of care, reimbursement is tightening along managed care models. We are required more and more to price our services for managed care contracts and for Medicare under prospective payment, rather than simply accepting reimbursement for our reported costs. For a long-term care organization involved in post-acute care, this can be a formula for going out of business, particularly if the organization is unable to track its operations and costs in detail. This is the challenge faced, certainly, by The Frontier Group, which serves 4,200 post-acute care patients daily, employing more than 4,500 skilled healthcare professionals in settings ranging from skilled nursing to rehabilitation to home healthcare.

Our emphasis traditionally has been on building a service base, while outsourcing the information management system (IMS) function. Over a year ago, though, it became clear to us that we needed a fully integrated internal IMS to monitor, in detail, whom we treat, how they are treated, at what cost and with what outcomes. It was also clear that there was no such system readily available on the market for an organization such as ours.

We formulated an arrangement with a Boston-based software developer called CareTools, which had a cost-accounting package that was about 75 to 80% of what we needed. The two companies worked together to develop an IMS customized to The Frontier Group's multisite organization. Eight months ago we rolled out "The Optimum Management Information System," or TOMIS for short. We are confident that TOMIS will take us into the next century in successfully providing post-acute care in a managed care environment.

TOMIS allows for seamless, real-time communication regarding patient care, referral activity, clinical protocols, cost allocations, customer/payer satisfaction, payer agreements and outcomes, all through a single point of entry. The basic data come from each specific patient encounter. From that, further data can be aggregated at various levels, ranging from individual managers, to regional managers, to division managers, to senior management, with more than 4,000 possible reports available. These are, of course, broken out and made accessible on a need-to-know basis, with patient confidentiality maintained throughout.

This new system is constantly under development. For example, although we are now relying largely on actuarial data for our critical pathways "templates" that monitor system performance and costs, our goal is to be able to use the system's own historical data to perform these functions. We feel we should have sufficient data to do so within a year or two. We are also developing a program that integrates what we see as the four components of "outcomes" measurement: clinical results, functional results, patient/payer satisfaction and cost. We believe that outcomes cannot be assessed without taking all four factors into account.

Why have we devoted time and effort to TOMIS? A two-word answer: managed care. I am not referring simply to the managed-care-type Prospective Payment System (PPS) implemented by Medicare, although that is challenging enough in its own right. The fact is, however, that the PPS's per diem approach is only an interim step. The PPS and, we think, all of managed care is evolving toward two other forms of reimbursement: case rates, which provide a fixed payment amount based on diagnosis and case complexity, and capitation (or subcapitation), providing a fixed payment per month for each member of a healthcare plan, regardless of each member's utilization.

Capitation, as a common form of post-acute care reimbursement, is probably several years away. Case rates, though, fall more into the here-and-now, and TOMIS is providing us with information critical to determining reasonable rates for cases of varying complexity. We categorize cases as "complicated," "medium" and "simple," and translating their cost implications simply can't be done without an integrated IMS like TOMIS.

Furthermore, Medicare's PPS is not the only managed- care-type prospect to consider these days in post-acute. Private managed care organizations (MCOs), which are enrolling large numbers of the under-age-65 population, are starting to question why they should suddenly lose members at age 65. Managed care is just beginning to address this in the New England area. In Massachusetts, for example, about half of people under age 65 are enrolled in some type of managed care plan, but only 13% of those over 65 are similarly enrolled; in Connecticut, those figures are 35% and 3%, respectively. TOMIS has enabled us to become poised for the inevitable growth in MCO participation.

Two important lessons we have learned in developing a customized IMS may be of interest to other providers looking to do the same. First, in formulating the partnership with CareTools, we incorporated a "user fee" system. This means that CareTools gets a percentage every time the system is used - i.e., their income is directly related to system utilization. This gives the company an incentive to continually keep us on the cutting edge.

Second, you must pay constant attention to the training of staff. Any facility that has computerized its clinical operations in even the most basic of ways has encountered problems with staff resistance and rejection; they are simply not accustomed to the idea of involving computers in their work. CareTools has helped us to develop and maintain a 24-hour-a-day, toll-free "help desk" to assist staff immediately with any problems they may encounter in using the system. It is further incumbent upon the provider organization, though, to maintain its staff's level of training, whatever the level of staff growth or turnover. New people must constantly be brought up to speed by existing trained staff. Failure to attend to this will result in an IMS that is anything but truly integrated or "seamless."

"Seamless integration" has become almost a cliche in today's multi-faceted post-acute care arena. It shouldn't be. It is still a goal that we are all trying to achieve. For The Frontier Group, TOMIS will be the key to accomplishing this.

Jonathan Sherwin is chairman and CEO of The Frontier Group, a Boston-based provider that operates The Optimum Care Network: The Center for Optimum Care, Optimum Home Health, Optimum Care Services and Optimum StaffingWorks. For further information, [phone], fax [phone].