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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 care—encompassing 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.
OCR for page 45
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 areas—could 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.
OCR for page 51
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 System—or
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
OCR for page 52
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.
OCR for page 53
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.
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Representative terms from entire chapter:
health centers
