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- Primary Care: 40 Stellar Community Health Centers SUMMARY DESCRIPTION Through implementation of proven models for redesigning care delivery, select community health centers (CHCs) would reinvent and substantially enhance primary careencompassing pre- ventive, acute, and chronic care for all CHC patients. These CHCs would then serve as national models for practices across the country for the delivery of stellar primary care. The Department of Health and Human Services (DHHS) will issue a Request for Proposals (RFP) to the nation9s approximately 859 community health centers and select 40 of these for demonstration projects in this category (see Box 3-1~.~ The demonstrations would be 3 years in duration, with the expectation that measurable improve- ments in care delivery processes would be realized within 18 months. All the demonstrations would include support for CHC leaders and clinicians to redesign care delivery and evaluate subsequent quality improvements and cost reductions. Each demonstration would provide the information and communications technology (ICT) infrastructure necessary to bring about this wholesale transforma- tion and align financial incentives to support the care delivery changes instituted. Finally, the demon- stration sites would be provided the resources necessary to disseminate what has been learned to other CHCs, primary care practices across the country, and the policy community. ~ The authors use the term CHCs, defined when this type of entity was first established. This term encompasses CHCs that do and do not receive Section 330 grants (see Box 3-1~. In 1992, an alternative term, federally- qualified health centers (FQHCs) was established and refers to CHCs eligible to receive Medicare payment for services provided (these same CHCs may or may not receive section 330 grants) (Federal Register, 1992~. In this chapter, the term CHCs is intended to encompass FQHCs. 41

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~ Primary Care BACKGROUND Primary care is a logical focus for demon- strations because it is an essential part of an effective health care system, a system that ide- ally emphasizes patient-centered, high-quality care while using resources efficiently (Institute of Medicine, 2001~. Specifically, research has shown that higher levels of primary care in a geographic setting are associated with Tower mortality rates, probably because primary care enables patients to obtain needed services before they are seriously ill, can improve health by helping patients control chronic conditions, and can provide sustained relationships between patients and clinicians (Gonnelia et al., 1977; Shi, 1992~. In addition, primary care settings are where the large majority of patients enter the health system and receive the bulk of their care, making such settings critical for achieving key preventive, health promotion, and chronic care goals (Bureau of Primary Health Care, 20026; Institute of Medicine, 1996~. All CHCs those that do and do not receive Section 330 grants would be eligible to apply for a demonstration grant, with up to 40 CHCs being selected as demonstration sites. If more than one CHC in a given state received a dem- onstration grant, they could channel a portion of their funds to the state-level primary care asso- ciation. Association staff could provide services such as data collection and reporting, infrast~uc- ture services, and patient education materials for CHCs within their state. Selecting CHCs as a mechanism to enhance primary care makes sense for a variety of reasons. CHCs are an established network of primary care practices. They have a strong base of innovation upon which to build that includes welI-developed programs for the management of chronic disease; an existing TCT infrastruc- ture that supports the collection and reporting of performance measures; recognition of the importance of wraparound services, such as patient education and self-management; and established relationships with government, ., 1 ~11 ., Box 3-1 How CHCs Are Paid Most CHCs receive Section 330 grants to enable them to provide services to the medically underserved, including the uninsured (Federal Register, ~ 996), with a small number of those that do not still meeting Section 330 eligibility requirements. These CHCs do not receive such grants because of funding constraints or because they do not want to meet increased reporting and financial requirements (Institute of Medicine, 2000). Both types of CHCs, however, receive funding under the same Medicare and Medicaid formulas (Bureau of Primary Health Care, 2002c). They are paid on the ba- sis of reasonable cost for providing services to Medicare beneficiaries. With respect to Medicaid, they are paid, at a minimum, on a per visit basis under a prospective pay- ment system (PPS) that went into effect in 2001 as part of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act. Using 1999 and 2000 CHC cost information, each state calculates a minimum rate that is 100 percent of the average of each CHC's reasonable costs. While each CHC has a unique rate, annual adjustments to this rate are tied to the Medicare Economic Index factor (Bureau of Primary Health Cares 2002a Koppen, 2001). If CHCs contract with Medicaid managed care plans, they receive payments as (continued on page 43)

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Primary Care 1 - (Corltlnuedf~rom page 42) does any other provider, which may take the form of capitated payment, discounted fee for service, or other arrangements. However, the Balanced Budget Act provides a wraparound payment to CHCs equal to the difference between their cost of providing care to Medicaid patients and the amount they receive from the plans (Koppen, 2002~. A revenue profile for the nation's CHCs in 2000 is shown in the following table, but excludes those CHCs that do not receive Section 330 grants. Of the nation's 859 CHCs, 1 1 1 do not receive such grants. Type of Revenue Percentage of CHCs* - Medicaid 34 Medicare 6 Section 330 and other Federal Grants 25 Nonfederal grants (state, foundations) 14 Self-pay 6 Other (public and private payers 15 Total 100 . SOURCE: Adapted from Bureau of Primary Health Care (2002d). *Excludes CHCs that do not receive Section 330 grants. - communities, and public health organizations. These features likely contribute to CHCs providing care that is at least as good as, and in many cases superior to, the overall health system in terms of better quality and lower costs (Falik et al., 1998; Institute of Medicine, 2000; Partndge, 2001; Regan et al., 1999; Starfield et al., 1994~. CHCs have a shared mission and shared clinician values, attributes well suited to a spirit of collaboration (Berwick, 2002; Stevens, 2002a). And the fact that about two-thirds of CHC resources come from either federal grants, Medicare, or Medicaid provides leverage for policy makers seeking to implement change. CHCs are located across the country in both urban and rural settings (Bureau of Primary Health Care, 2002a) and serve a high proportion of Tow-income and poor patients. They are community-based and are required to have a majority of active CHC clients as board members (McAiearney, 2002~. Consequently, they are in a position to understand and respond to local and patient needs. CHCs are highly variable in terms of geographic location; funding mix; and involvement in chronic care col- laboratives, which relates to their ICT capacity. They also vary in particular populations served (e.g., poor fami- lies. migrant workers. the homeless school-age children), although in gen- eral CHCs serve a high proportion of the poor (to-thirds of patients are at or below the poverty line) and two- thirds are racial/ethnic minorities (Bureau of Primary Health Care, 2002d). Given this patient mix, overall improvements in care delivery should help to close the nation's existing ra- ~ cia anc socioeconomic gaps In care.

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f Primary Care Finally, the Administration has focused on CHCs as a way of providing services to the uninsured and other vulnerable populations. The Administration has stated that it plans to add 1200 new or expanded CHC sites2 over the next 5 years and to increase the number of people served from 11 to 16 million (U.S. Department of Health and Human Services, 2002~. The Administration also recognizes the role of CHCs in providing important emergency response programs in urban settings. This year, the Health Resources and Services Administra- tion (HRSA) received $175 million to create new CHCs, expand existing ones, and enhance emergency response programs (U.S. Depart- ment of Health and Human Services, 2002~. In implementing proven models to redesign care delivery, demonstrations in this category would build upon and significantly expand the efforts of leading CHCs that are actively and successfully managing a select number of chronic conditions so that their care manage- ment approaches can be applied to all condi- tions and all health center patients.3 The demon- strations would help extend existing innova- tions, detailed below, to the next level so that all CHC patients wall have ready access to high- quality,' science-based, state-of-the art care that is patient-centered and safe and allows for patient decision making and self-management. Ultimately, these demonstrations should lead to improved primary care across the country, as well as strengthen the nation's health care safety net. Existing Innovations at CHCs The demonstrations will build upon CHCs' existing innovations in redesigning care deliv- ery, which are supported by information tech- nology and rely upon reporting and monitoring related performance measures. . . Chronic care management Starting in 199S, five CHCs began using the Chronic Care Model (Wagner et al., 2001) and the Institute for Healthcare Improvement (Imp models to redesign care for patients with diabetes. This initial effort has provided a springboard for CHCs to redesign care for patients with a number of chronic condi- tions, including cardiovascular conditions, asthma, depression, and HIV. Box 3-2 describes an example of a successful CHC program that used these models in improv- ing care for patients with asthma. One of the central aspects of these models is a learning collaborative, whereby diverse organiza- hons define common goals and share ideas, strategies, and methods including redesign ~ ,% . . . O: : care processes Ior ac ~1evmg 1mprove- ments in clinical care for a specific condi- tion. To date, about 500 CHCs have been involved in a collaborative of some kind (National Coalition on Health Care and Institute for Healthcare Improvement, 2002a; Stevens, 2002b). Electronic patient registries Electronic patient registries which at a minimum include an individual care plan for a specific disease, health status information, visit notes, and the capacity to generate summary statistics related to the individual and popu- lation~xist in about 500 CHCs and sup- port the collaboratives noted above. The latest generation of registries, in place in over 140 CHCs and known as the Patient Electronic Care System, adds the ability to manage multiple chronic diseases, the latest 2 CHCs may have one or more sites, with the average having three or more (Institute of Medicine, 2000~. 3 If the center's patient population reflects the population as a whole, at least 45 percent have one or more chronic conditions (Partnership for Solutions, 2001~. In addition, studies have shown that adult low income CHC users have a higher prevalence of certain chronic conditions, such as hypertension and diabetes, than adult low income persons in the general population (Bureau of Primary Health Care, 2002a; Mathematica Policy Research, 1998a; Mathematica Policy Research, 1998b). The number of uninsured served by CHCs is 3.9 million, but this figure does not include those served by CHCs that do not receive Section 330 grants. Therefore, the total number of uninsured served by CHCs is likely larger.

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Primary Care evidence-based guidelines and related prompts, and the capacity to generate lists of patients in need of care (e.g., follow-up visits, laboratory tests). The system is avail- able flee of charge to CHCs that have already been involved ire the Bureau of Primary Health Care's chronic disease programs. The registries are seen as a step- ping stone to computer-based patient records currently in place in just a few CHCs (Langley, 2002a, 2002b).4 Performance measures Data collection and reporting performance measures were initiated in the early 1 990s and encom- passed a small number of preventive care measures; now performance measures are mostly linked to the coliaboratives. They include some core, standardized measures to allow for comparison and learning across CHCs, as well as organization-specific measures. ~ the future, the CHCs plan to make their performance data available to the public (Stevens, 2002b). Box 3-2 CHCs Demonstrate Success in Managing Chronic Illnesses: A Case Example The Hill Health Center in New Haven, Connecticut, began an asthma improvement program in 2000 with one clinician and 30 patients (National Coalition on Health Care and Institute for Healthcare Improvement, 2002b). The program has now grown to serve over 900 patients in both the main clinic and eight school-based and primary care satellite clinics. The program has resulted in significant reductions in emergency department visits and school absenteeism. It has also increased the number of days that patients are free of asthma symptoms, outstripping national averages. Hill Health Center adapted existing models (see Box 3-4) to aid in the redesign of care delivery that led to these improvements. The asthma program was initiated with the development of a patient registry to identify patients. The registry allows for tracking of measures related to individual patients and the population as a whole, more flexible scheduling of appointments, and identification of patterns. Responsibilities for care, such as taking of histories and patient education, are now divided among interdisciplinary teams, which include physi- cians, community health workers, and registered nurses. The Hill Health Center also includes patient education in groups in its improvement model. Patients are encour- aged to manage their conditions through the development of an action plan, which incorporates a patient goal. They are also provided self-management tools, such as videos, comic books, peak flow meters, and brochures. Continuing education of providers has been a priority as well. The center conducts in-service meetings to reinforce the use of the latest evidence-based guidelines and protocols for asthma care. It also uses an asthma assessment and treatment plan flow sheet and posts guidelines in color-coded laminated charts in easily accessible locations. (Continued ore page 46) 4 The term "computer-based patient record" encompasses electronic medical records and is used for consis- tency throughout this report. _

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46 Primary Care (Continuedpom page 45) The Hill Health Center has partnered with multiple community organizations to address the environmental factors that can trigger the disease, such as pests, mold, and ventilation systems, as well as to provide educational materials, activities, and equipment for its patients. These organizations have included school nurses, the Visit- ing Nurses Associations, the local public Community Action Agency, the American Lung Association, and pharmaceutical companies. To measure the improvement achieved through the program, the center developed a set of tracking indicators, but unfortunately did not report (or perhaps even collect) baseline data. These indicators have revealed the following: Medication used to control asthma has increased to 1 00 percent. School absenteeism has been reduced to less than ~ day per 2 weeks since January 2001. Emergency visits due to asthma have been reduced to less than ~ percent on average per 2 weeks since February 2001. Peak flow rate performance has increased to greater than 80 percent. An asthma action plan is provided to ~ 00 percent of patients. The number of symptom free days has increased to almost 80 percent (the national standard is 70 percent). Through these improvements, the Hill Health Center has reduced costs as a result of fewer hospitalizations and emergency visits. This cost reduction has enabled the center to negotiate with managed care organizations to cover key medications and medical equipment and to make the reimbursement process smoother, although the center itself has not benefited financially from the improvements achieved. Given the growing experience of CHCs with redesigning care delivery and measuring the results 500 CHCs have participated in a learn- ing collaborative, with many being able to point to impressive results (National Coalition on Health Care and Institute for Healthcare Im- provement, 2002b) private primary care prac- tices could likely benefit from what CHCs have learned along the way. Chronic care collabora- tives based outside of CHCs have included private primary care practices and hospitals as well as CHCs (Wagner et al., 2001, 2001), and organizers point to the value of this cross- fertilization (Berwick, 2002~. CHCs have also developed models for providing effective inter- disciplinary and culturally competent care to patient populations that have a high proportion of ethnic/racial minorities, including those reli- ant on supportive services (Politzer et al., 2001) models that private primary care prac- tices could perhaps adapt as they work to imple- ment and support care teams and attempt to close existing equity gaps (Institute of Medi- cine, 2002~. Finally, CHCs have a history of integrating physical and mental health services, which leading primary care experts have long advocated to enhance quality (Institute of Medi- cine, 1996~. GOALS Demonstration projects in this category are intended to achieve the following goals for all patients as appropriate:

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f Primary Care 1. High-Quality, patient-centered care Redesigned preventive, acute, and particularly chronic care that results in measurable decreases in severity of illness and increased use of preventive/ primary care, eventually leading to reductions in incidence and disease burden Care responsive to patients' wishes and social circumstances Effective clinical care teams that meet varied patient needs 2. Participatory care Patients sharing actively in all clinical decisions that affect them Patients supported in learning how to care for themselves and, if they wish, to manage their own conditions 3. Open access Access to appointments without delay, including same-day appointments Patient access to care through varied and convenient mediums , ~ 4. Evidence-based, safe care Science-based, high-quaTity, state-of- the-art care that is safe and reliable Expert systems for quality improve- ment, including error detection and reporting ., .^ Evaluation of CHC demonstration efforts and communication of results to the larger practice community 6. Efficient, effective care Reduction in inappropriate hospital visits Other care delivery mechanisms that are less costly and equally or more effec- tive, such as group visits, e-maiT consults and lay health worker visits Improved medication management 7. Equitable care Targeting of populations to meet diverse patient needs and reduce dis- parities A community orientation that gets diverse stakeholders involved in crea- tive solutions for reducing ethic and racial disparities DEMONSTRATION ATTRIBUTES Patients' confidence that they will not be subjected to invasive, harmful care that will not help them 5. Shared best practices Sharing of best practices related to care delivery redesign and other learning across CHCs Patients' confidence that the best known approaches to care will be used to help prevent, address, and manage their illnesses, particularly in the case of chronic conditions The goal is for CHC demonstrations to become models for exemplary primary care practices over the next 3 years. Given this short timeframe, in all likelihood it will be prudent to select CHCs with an established track record in successfully implementing care delivery innova- tions. There is, however, no one size fits all approach to innovation. Each demonstration site would take into account its unique history, capacity, existing relationships, location, and distinct populations served while emphasizing four basic attnbutes: a patient-centered focus; investment in and implementation of ICT; shared learning and accountability; and a supportive financial environment. By way of example, Box 3-3 presents a chart that illustrates what a leading CHC- which has already achieved innovation in all four of these areascould accomplish over the 3-year demonstration period. Given this rela-

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Primary Care Box 3-3 Potential Accomplishments of an CHC Key Attributes Patient-centered focus Current Reality Chronic care colIaboratives in place for two conditions, selected providers. Demonstration Vision Care delivery redesigned for all conditions, all patients; full participation of all providers. Computerized decision support integrating EMRs, secondary databases, and protocols at point of care. Participation in clemonstra- tion-wide colIaboratives; reporting of performance Information and communi- cations technology Patient registry for To conditions; work under way to transition to electronic medical records (EMRs). Participation in two condi- tion-specific learning colIaboratives; collection and reporting of select proc- measures that show lower ess and outcome measures. indications of disease sever- ity, reduced emergency departmenVhospital use, increased use of preventive/ primary care, and progress on other quality indicators. Visit-based payment, except Payment innovations to for the uninsured; staff on support more extensive care salary; achieve some cost savings resulting from inno- vations, but all accrue to payers. Shared learning and accountability Financial environment , , coordination and alternative care delivery vehicles; ex- perimentation with reward- ing teams and individuals, and centers for exemplary performance. lively short time frame and the ambitiousness of the goals outlined above, most CHCs would be limited to accomplishing these results in fewer domains. Patient-Centered Focus As noted, demonstration CHCs would redesign and transform the way care is delivered for all patients so that eventually care for all conditions as well as routine preventive care is transformed. By adding collaboratives, the dem- onstrations may extend existing models they have been using the Chronic Care Model and the WI models for health care organizations and clinical office practices (see Box 3-4) to other conditionsor consider other approaches. These existing models are predicated on a well- developed ICT infrastructure, stress enhancing care delivery through better integration and coordination, and involve patient self- management and sharing of best practices and data across the organizations involved. The demonstrations would also need to make effec- tive use of interdisciplinary teams, maximizing clinician and paraprofessional skills in the proc- ess (Milstein, 2002~. Each CHC patient would receive a care guide to help in navigating and planning for care within and outside of the CHC. These care guides would reside in the electronic patient registry or computer-based patient record; in- cTude data from other organizations from which the patient receives care (e.g., laboratory or

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Primary Care hospital); and have buiTt-in supports, such as electronic and phone reminders, to help cTini- cians and patients in monitoring care against an agreed-upon plan. The care guides should serve to educate patients, would help foster patient self-management, and should aid in integrating and coordinating care, so that a patient can eas- ily move from one setting to another without a great deal of disruption. Two existing efforts provide some guidance on how CHCs have been integrating care across settings, and may serve as models for CHCs that have not yet focused on enhancing care delivery beyond the* centers. The first is the Integrated Service Development Initiative (ISDI), which began in 1994 and is focused on integrating services across Bureau of Primary Health Care (BPHC)-supported programs and other safety net providers. In addition to integrating admin- istrative and financial injunctions, the ISDI projects have also focused on clinical integra- tion, such as creation of specialty referral net- works and standardized disease management protocols and integration of management infor- mation systems (Health Resources and Services Administration, 2002~. Another BPHC-initiated Box 3-4 Care Delivery Models Adapted by CHCs CHCs have adapted and integrated leading models for the redesign of care deliv- ery, including the Chronic Care Mode! (CCM), developed at Group Health Cooperative of Puget Sound, and improvement models designed by the Institute of Healthcare Improvement ('HI). Approximately 500 CHCs have used these or other models to form colIaboratives that have redesigned and further integrated care. The CCM, intended to improve the care provided to patients with chronic illness and their families, is a population-based approach that emphasizes evidence-based, planned, and integrated collaborative care (National Coalition on Health Care and Institute for Healthcare Improvement, 2002a; Wagner et al., 2001; 1996~. The mode! reliefs on decision support technology, such as a computerized patient registry, and the support of community organizations, such as schools, government, nonprofits, and other organizations. A primary goal of the CCM is interaction between an informed, ac- five patient and a proactive, prepared practice team. A second improvement model, developed by ~HI, is called the PDSA (Plan-Do- Study-Act) rapid-cycle improvement mode! (Institute for Healthcare Improvement, 2002b). This mode! complements the CCM, and the two can be implemented together by multidisciplinary practice teams. The PDSA cycle involves planning a change, try- ing it, observing the results, and acting on what is learned. The initial step is to set a clear aim for improvement and form a team that represents all of the areas of exper- tise that will be involved in the effort, including members with leadership positions, technical expertise, and day-to-day experience. This team then works to develop measures that can be used to determine whether a specific change has actually led to an improvement. Once the aim, team, and measures have been established, a change can be tested in the real work environment using the PDSA model. In addition, PHI is undertaking another initiative, Idealized Design of Clinical Office Practices (IDCOP) (Institute for Healthcare Improvement, 2002a), with the aim of sig- nificantly improving the performance of clinical office practices through dramatic and sustained system-ieve' changes. IDCOP may become a third improvement mode' that practice teams can adapt to improve and integrate care. ~1

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~ Primary Care effort is the Community Access Program, which currently supports 136 community-wide efforts in urban, rural, and tribal areas. These efforts are focused both on building integrated health care delivery systems across sectors in a com- munity so as to create seamless care, and on re- ducing unnecessary and duplicative functions. Savings that result from such waste reduction are currently captured by the CHCs and rein- vested in the system (Health Resources and Services Administration, 2002~. CHC patients should also have access to al- ternative ways of communicating with their clinicians and receiving needed services. A lim- ited number of CHCs currently provide patient education and counseling in group settings (Stevens, 2002a). Such approaches have been shown to increase patient compliance with care plans, enhance patient satisfaction, and reduce costs (Henry, 1997; Kilo et al., 2000; MasIey et al., 2000~. All of the demonstrations will be encouraged to offer such an option. Some CHC patients, albeit a limited num- ber, currently communicate with their clinicians by e-mai! or through lay health workers, who are recruited from the community for outreach and treabnent follow-up, home visits, and other duties. Demonstrations should be encouraged to extend remail as an option to all patients inter- ested in such arrangements, with the provision that reimbursement will support these e-consults. Although some clinicians mav be ;- day appointments, which have been shown to reduce no-shows, increase patient visits, and enhance gross revenue without requiring addi- tional staff (Darves, 2002; Gordon, forthcom- ing; Murray and Tantau, 2000; White, 2001~. Finally, depending upon the populations served, CHCs should consider using demonstra- tion funds to further tailor and customize care so they can meet the needs of racial/ethnic minor- ity patients more effectively. This goal might be accomplished by translating patient education materials into appropriate languages, working with community groups to address the health needs of difficult-to-reach populations, or undertaking other strategies that can help the CHC provide culturally sensitive care. Investment in and Implementation of Information and Communications Technology initially uncomfortable with communicating by email, many will likely find that it saves time, and if the financing mechanism is supportive, will not cause a loss of revenue to the CHC because they are foregoing an office visit. Lay health workers, supported by demonstration funds, will be called upon to help in the imple- mentation of demonstration goals. For example, they might visit asthmatic patients' homes to provide tips on ways to reduce allergens (National Coalition on Health Care and Institute for Healthcare Improvement, 2002a) or provide follow-up education for new mothers on preven- tative baby care. Demonstrations also should be encouraged to give patients the option of scheduling same- ~3 The Tonger-term goal for the demonstrations would be to have computerized decision support systems that integrate computer-based patient records, secondary databases, and scientifically based protocols at the point of care so that patients receive state-of-the-art, reliable, high- quaTity care. The computer-based patient record should be accessible to patients and clinicians on an as-needed basis, and will promote effec- tive care delivery, education, and shared deci- sion making. The CHCs, as they have in the past, would be encouraged to work together in further developing ICT; such technology should conform to national data standards where they exist (see Chapter 4~. As noted, few CHCs currently have computer-based patient records, although exist- ing electronic patient registries and the Patient Electronic Care System provide an important building block by capturing care plans, proto- cols, and patient information and allowing for ongoing monitoring. A computer-based patient record is the next step, enabling integration of all of a patient's clinical information and the exchange of such information with patients and, when warranted, with outside organizations.

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Primary Care Such exchange would be predicated on having appropriate privacy protocols in place. With the computer-based patient record as a foundation, CHCs would be able to transition to an environment that no longer relies so substan- tially on paper transactions. Ultimately, the goal is to have a Web-based system whereby infor- mation, as appropriate, is accessible to all the CHCs and the relevant organizations in a seven community. For example, such a system allows for electronic order entry for medications and automated monitoring of contraindications and allergens; exchange of patient information, such as hospital and emergency department discharge information, with other institutions; receipt and integration of laboratory and imaging center data; integration of information from specialty consults; and access to protocols for major therapeutic decisions (MiTstein, 2002~. CHCs in California are currently working to Implement a computer-based patient record system (Bureau of Primary Health Care, 2002b). A number of California-based health centers that received funding from the Tides Foundation for ICT investments, including those designed to advance the use of computer-based patient records,. have reported that they have been able to increase reimbursement, improve immuniza- tion rates, and enhance follow-up for patients with chronic disease as a result (Brailer, 2002; The California Endowment, 2002~. Demonstration CHCs could continue to work with private vendors to evolve current products into computer-based patient records- an example being the Aristos Group, which de- veloped the Patient Electronic Care Systemor choose to partner with other organizations that have the necessary expertise. On the local level, hospitals within the Veterans Health Admini- stration (VHA), which has developed and implemented a computer-based patient record system, might serve as a local resource for CHCs in this regard. In addition to the automation of clinical records, CHCs would need to establish a digital connection between clinicians and patients for those who desire this form of communication, including e-maiT and fax communication, Web- based dissemination of information, and elec- tronic same-day scheduling and reminders. Although few CHCs currently have such con- nections, and the populations served may be less likely to use such forms of communication as compared with the general population (Newburger, 2001), such linkages are an impor- tant component of an exemplary primary care practice, and provide important tools for provid- ing preventive care information and managing patients with chronic illnesses. How rapidly an ICT infrastructure can be developed would depend in large part on each CHC's existing capacity. New CHC should, at a minimum, develop a highly evolved Patient Electronic Care System. The goal for others would be development and use of a computer- based patient record system. For those that have such a system in development or in place, migrating to a "paperless" environment should be the focus. Shared Learning and Accountability An important foundation of the existing condition-specific collaboratives is the sharing of information across CHCs through electronic and face-to-face meetings, site visits, informal and formal assessments, and periodic reports. With more collaboratives coming on line, the aggregation and reporting of this information only grows in importance so that CHCs can understand what works, assess the benefits for patients, and determine the cost of such efforts. To this end, there needs to be a national CHC learning collaborative that spans all condi- tions likely housed at HRSA that collects data from the demonstrations and provides some direction to the participants in an advisory capacity. The kinds of performance data currently reported by the CHCs provide a good founda- tion for the more extensive data collection and reporting envisioned for this demonstration category. Each demonstration CHC should build upon its current reporting activities and set benchmarks for improvement, with the goal of

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f Primary Care demonstrating to the public that CHCs can sub- stantially reduce the severity of many conditions (e.g., heart disease, diabetes, asthma); increase the numbers of patients who avail themselves of scientifically established screening and health behavior counseling programs; and reduce the use of emergency departments and hospitals, thereby reducing costs. The national learning collaborative should establish a set of core performance measures to be reported by all the demonstrations- building upon existing CHC core performance measures to allow for comparisons and benchmarking. : - In addition to the collaborative, the Agency for HeaTthcare Research and Quality (AHRQj, which has a grant to test and compare two dif- ferent models for improving diabetes care in 40 CHCs in the Midwest (Agency for Healthcare Research and Quality, 1999), should receive further support for taking a comprehensive look at all 40 demonstrations; evaluating their efforts individually and collectively; and discerning whether there is a business case to be made for the overall effort, in other words, whether the benefits derived from the demonstration out- weigh the costs. Lineally, the national learning collaborative, with support and evaluative information from A~Q, should take the lead in disseminating the innovations and best practices resulting from the demonstrations to the broader primary care and policy communities. This dissemination function should be provided adequate support, given that it is the mechanism through which primary care practices can learn from CHCs about how to redesign and improve care. In addition to leaders from the CHCs, those involved in the dissemination efforts should include leaders in primary care who can help in translating learning from CHCs to traditional . . primary care practices. Financial Environment Some of the demonstration components would require innovation with respect to pay- ment, which is now mainly visit-based except in the case of the uninsured. In the case of Medi- _ 1 ~1 caid, waivers may be required and necessitate state involvement. Payment innovations would support CHCs in their efforts to provide group counseling and education visits, more extensive care coordination, and other care that does not result in a billable clinician visit (e.g., e-maiT consults). Organizations must also experiment with paying for services rendered outside of the CHC, perhaps by lay workers, where evidence suggests that such services could enhance qual- ity, by, for example, systematically reducing allergens in homes of patients with asthma. Cur- rently, CHCs either are not compensated for providing such services or receive less-than- adequate support by relying on Section 330 grants. CHCs also should be provided incentives to include hospitals, health plans and insurers in the collaboratives because of the importance of managing care across settings, particularly care for those with chronic conditions. Including in- stitutions outside of the CHCs will allow for sharing of data, problem solving about how to improve care coordination and integration, and how to reduce costs, e.g., emergency depart- ment and overall hospital use. See Box 3-2 and Box 3-5 for examples of a CHC managing care across settings. CHC staff, the health centers themselves, and other institutions that serve CHC patients should also share in the rewards when they demonstrably enhance the quality of and reduce costs of patient care. At present this is generally not the case. The expectation for the demonstra- tions is that through redesign of care delivery, patients would receive better-quaTity care that is less costly because waste will be eliminated. Public programs would certainly benefit from those savings, but as an incentive and as a matter of equity, so should CHCs and the cTini- cians who work there. With respect to CHCs, such incentives may be at the CHC team or clinician level and could also encompass confer- ence attendance, assistance with research, and other nonmonetary rewards. Box 3-5 describes a case example of CHC efforts to reduce health care costs.

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Primary Care Box 3-5 Reducing Costs: A Case Study in Mississippi In Hinds County, Mississippi, CHCs are working with four local hospitals to reduce emergency department and hospital use by uninsured persons. The program, supported by The Robert Wood Johnson Foundation and the Health Resources and Services Administration, includes follow-up with an uninsured person who has made a hospital visit to determine its appropriateness, provides course! on what is an appro- priate visit, and links the individual to a regular source for primary care. Program lead- ers hope that if the program can demonstrate savings, the hospitals can be convinced to support its operating costs. In 2003, the program will be rolled out to Medicaid bene- ficiaries (Jackson Medical Mall Foundation, 2002~. The Medicaid agency has report- edly said that if costs can be kept budget neutral, CHCs and local hospitals will be able to share in the savings (Shirley, 2002~. Finally, to permit analysis of the business case for redesign as well as assessment of any related gains and how they should be distnb- uted, there should be a robust cost accounting system for each CHC that separates out start-up costs for the demonstrations and ongoing costs and benefits, as measured by clinical quality indicators and other measures. Use of such a system would go a long way toward helping policy makers assess whether the demonsha- tions should be replicated across all CHCs, and enable primary care practices across the nation to decide whether to embark upon CHC- inspired redesign efforts focused on delivenng stellar primary care. REFERENCES Agency for Healthcare Research and Quality. 1999. "Grant Number: 1 R01 HS10479-01; PI Name: Chin, Marshall; Project Title: Improving Diabe- tes Care Collaboratively in the Community." Online. Available at http://www.gold.ahrq.gov/ PrintView. cfm? GrantNumber= 1 %2 OR01 % 20HS10479-01 [accessed Oct.28, 20023. Berwick, D. (Institute for Healthcare Improvement). 16 July 2002. Federally Qualified Health Cen- ters. Personal communication to A. Greiner (Institute of Medicine). Brailer, D. J. (CareScience). 10 October 2002. Cali- fornia Community Health Centers Project. Personal communication to S. M. Erickson (Institute of Medicine). Bureau of Primary Health Care. 2002a. "Community Health Center Program." Online. Available at http ://www.bphc.hrsa. gov/CHC/chcmain. asp "accessed July 15, 2002a]. . 2002b. "Community Health Center Pro- gram: BPHC Electronic Medical Record Re- sources." Online. Available at http://www.bphc. hrsa. gov/CHC/CHCInitiatives/emr.htm Accessed Sept. 12, 2002b]. . 2002c. "FQHC Look-Alike Program." Online. Available at http:/lbphc.hrsa.gov/CHC/ CHCInitiatives/fqhc_lookalike.asp [accessed July 15, 2002c]. . 2002d. "Uniform Data System National Rollup Calendar Year 2001 Data. (Exhibit Ao Total Revenue Received by BPHC Grantees)." Online. Available at http://www.bphc.hrsa.gov/ uds/data.htm Accessed Sept. 10, 2002d]. Darves, B. 2002. A Better Way to Practice. Physi- cians Practice (Jan-Fete) Falik, M., J. Needleman, J. Korb, and N. McCall. 1998. ACSC Experience by Usual Source of Care: Comparing Medicaid Beneficiaries, CHC- Users and Comparison Groups. Wheaton, MD: MDS Associates. Federal Register. 1992. Medicare Program; Payment for Federally Qualified Health Care Services. Rules and Regulation 57 `1 14~:24961. _

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