As the U.S. healthcare system moves forward generally into the realm of population health management and value-based delivery of care and purchasing, it might be useful to note that federally qualified health centers (FQHCs), which serve the poorest Americans, have been operating within an operating context that is community-oriented and value-based, for decades now. What’s more, because the nation’s FQHCs have been funded by the federal government to serve underprivileged communities, those community health centers have long been pioneers in population health management strategies, in order to best serve their patients and communities.
The federal healthcare agency most extensively involved in working with FQHCs, the Rockville, Md.-based Health Resources and Services Administration (HRSA), funds well over a thousand health centers that deliver primary and preventive care to millions of low-income patients in every state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and U.S. possessions in the Pacific, according to the Wikipedia entry on HRSA.
Recently, HCI Editor-in-Chief Mark Hagland spoke with Suma Nair, director of the Office of Quality Improvement in the Bureau of Primary care at HRSA, regarding population health efforts at FQHCs and the leveraging of data and analytics for those efforts. Nair will be a member of a panel entitled “Data and Analytics: Strategies for Population Health Management,” to be presented at the Health IT Summit in Washington, DC. That event will take place June 16-17, 2015, at the Ritz-Carlton Tyson’s Corner in McLean, Va., and is sponsored by the Institute for Health Technology Transformation (iHT2, a sister organization to Healthcare Informatics, under our corporate parent company, Vendome Group LLC). Below are excerpts from that interview.
Tell me about your agency’s involvement in supporting population health management efforts in FQHCs.
Much of our effort focuses on our Community Health Center Program, with its primary and preventive care orientation. The reality is that federally qualified health centers are the safety net for our entire healthcare system when it comes to primary care. So there are many potential collaboration and partnership opportunities.
Our Community Health Center Grant Program funds about 20 percent of the FQHCs’ budgets. We’re funding close to 1,300 FQHCs, according to our latest statistics. They have to be federally qualified to get our funding. FQHCs are celebrating their fiftieth anniversary this year, and are an essential provider in our healthcare system. The mission around supporting them is to optimize is access to comprehensive, high-quality services. We currently have about 1,300 organizations, with about 9,000 delivery sites serving (as of 2013) about 21.7 million patients. When we look at the numbers in Census data, one in 13 people in the US are getting services from FQHCs. And they really are focused on the most underserved, disadvantaged patients. In addition, we have some information on the makeup. The vast majority of our patients, over 62 percent, are racial or ethnic minorities; almost a quarter are better served in another language, and 35 percent, in 2013, had no insurance, but we expect a shift in 2014 numbers based on the ACA [increased access to affordable health insurance through provisions of the Affordable Care Act].
So we’re primary care providers for a special population with additional needs. So that vision of serving this population has been important. So I’ll share some examples of how FQHCs have been leaders in leveraging technology. With regard to EHRs [electronic health records], a little over a decade ago, fewer than 25 percent of FQHCs had adopted EHRs, but by 2013, 96 percent had done so, and had participated highly in CMS’s meaningful use program [the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act, under the Centers for Medicare and Medicaid Services], mostly on the Medicaid side. Because 40 percent of the payer mix in FQHCs is Medicaid. So there’s been great traction in that program; significant percentages have attested to Stage 1 and many are in Stage 2. Along with significant advancements in care delivery transformation—right now, 61 percent of our FQHCs are fully qualified patient-centered medical homes.
What are the main things FQHCs are doing in population health right now?
Health centers actually started with that form of delivery organization, with that concept of community first, with being a one-stop shop with being a jobs program, having a food program, everything. So many of them are saying, well, we’ve always done population health. So they’re really just managing those patients across care settings now. And they have a strong quality improvement focus and infrastructure—in fact, that’s a key requirement for participation in our program. So you can just imagine when HIT became pervasive and also the PCMH care model, they really saw a huge opportunity to leverage the technology. And beyond that, they’re moving into health information exchange. And about 40 percent are doing some kind of HIE already, much of that being at the community level, with some at the state level. And another 30 percent are working towards that.
They’ve also moved beyond EHR adoption to data warehousing. So the health information exchange piece is important; and they’ve also invested in data warehousing work to benchmark themselves against other health centers and state averages, to really improve care.
Also, as you know, the Institute of Medicine has this idea of a continuously learning healthcare system. And we’ve talked about comparative effectiveness research and translating academic research into practical transformational work, and in that context, about half of our health centers are participating in some form of research. And 32 practice-based research networks, per AHRQ [the Agency for Healthcare Research and Quality] have FQHC involvement. So we’re making sure our populations are not being left behind in research, either. So that’s exciting.
And beyond fulfilling the meaningful use requirements associated with surveillance, to better target limited health resources, they’re focusing increasingly on chronic illness rather than the typical reportable diseases.
What have the biggest lessons learned been so far in FQHCs around leveraging data for population health and care management purposes?
I don’t think it’s significantly different from other use cases in healthcare. The early adopters of EHRs were taking whatever the NextGens and Epics of the world were selling them, and tweaking their solutions. And the next step has been the patient focus. The governance structure… There’s a keen look to, as you’re looking at this and getting the data and information, making sure you’re most focused on the patient. So in terms of the lessons learned so far, they’re the typical ones: once you’ve built these systems, and have gotten the data into the EHR, now, how do you extract it and make changes based on the insights you’re gleaning?
And the alignment of all the health center stakeholders working all together and getting the extra capacity to use the data—identifying best practices from identified gaps, health centers have made some great progress in that arena.
So that’s a big lesson. As we think about supporting the health center program nationally, we’re continuing to make investments to improve quality. And part of what we’ve been doing is getting our Uniform Data Set to be transparent on the HRSA website, all the way down to the individual health center level. You can see that data on our website. That has helped health centers to really look at their data and improve their care delivery and outcomes. Demographics: age, gender, race, ethnicity, payer mix… Data on staffing, so numbers of providers and types of visits associated with that. So you see trends over time, and investments we’ve made from the health center program side. We provide not only your typical care, but also, integrating oral health, preventive health, HIV care, into overall care. And we’ve focused on a team-based model to help everyone work at the top of their license—maybe you need a team to support you in maintaining your health management regimen, as a diabetic.
Isn’t that where healthcare is headed, in any case? As we as a healthcare system become one that will have to operate in an environment of strained resources and increasing needs, per the aging of the population and an explosion in chronic illness, it seems that FQHCs will be seen as leader organizations.
Yes the Secretary of Health and Human Services [Sylvia Mathews Burwell] has really focused on that, with delivery system reform efforts. Effective primary care, like effective prevention, is really the crux of reducing costs and more importantly, keeping people healthy, and health centers are really essential in moving care closer to patients and delivering high-volume, high-value care. Some of the hardest areas to move forward on, in terms of hypertension and diabetes outcomes, is really moving the needle forward on engaging patients in their care, and health centers are key to that.
Can you speak a bit further to the accomplishments being made in FQHCs and the ways those accomplishments are pointing to the future?
Yes, the IOM put forward that report about being a continuously learning healthcare system. And, per the entire spectrum of public health—if people weren’t already aware of that, health centers are an important part of the primary care network, and they have the understanding and the knowledge. Other areas have been technology innovators and have done Lean Six Sigma and other important things; but the nuanced, important element in the health center program is that they know how to care for the most needy patients, and know how to disproportionately impact the lives and health of these patients. And as other organizations think about, oh, I need to form an ACO, and I don’t know how to do this… As people think about horizontal versus vertical integration, people could take lessons from health centers in what they’ve done because that will help us all drive forward and really get towards that Triple Aim of better health, smarter spending, and improved value. So the one-liner is that when we think about population health management nationally, I think health centers are an important piece of that puzzle.