Community Health Center Model

MODULE 1: AN INTRODUCTION TO THE COMMUNITY HEALTH CENTER MODEL Unique Model of Care that Facilitates Research primary care providers, high infant mortality, high poverty, and/or high elderly populations.2 The Federal Health Center Program, also known These areas tend to have high risk for health as Community, Migrant, Homeless, and Public disparities and poor health outcomes and have Housing Health Centers,1 began as a “War on high need for health care services. Poverty” program targeting medically Serve all without regard to insurance underserved communities. From their founding status of ability to pay. Health centers provide under the Public Health Services Act of 1965, services to anyone and everyone who walks health centers were designed to remove through their doors. They provide discounts to entrenched barriers to care, improve uninsured patients in need with fees adjusted population health, narrow health disparities, based on an individual’s ability to pay. and generate system-wide health care savings. Provide comprehensive, coordinated In fact, a wealth of literature demonstrates primary and preventive care services. Health their successes along these lines, as well as their centers must provide a broad array of primary capacity constraints.1 and preventive care, as well as “enabling services” designed to remove barriers to care. Health center program requirements are Health centers are also encouraged or in some grounded in federal statute and regulation, cases required to provide behavioral health, touching on governance, need, services, dental, vision, and pharmacy services. Health financing, and management – which in centers are also required to collaborate with combination establish a unique, patient- and other local health and social services providers, community-centered approach to care that sets though strong referral networks in many places health centers apart from other providers. do not exist. These include: Provide culturally competent care. Services are required to respect and respond to Community governed. At the heart of their patient population’s cultural preferences. the health center model is the requirement that Conduct ongoing needs and quality at least 51% of health center governing board improvement (QI) assessments. Health centers membership be made up of active patient must have QI and quality assurance programs, users, thereby ensuring that health center and must conduct regular, formal assessments programs are responsive to community needs of community needs. and priorities. This governance structure Report data. Health centers must oversees all areas of health center operations – report data annually to the federal Health including the hiring and firing of health center Resources and Services Administration (HRSA) Directors – thereby functioning as something on patients, services, quality, and finances. much more than advisory boards. Locate in or serve medically These requirements are designed to ensure that underserved areas. These areas are designated health centers improve access to high quality, by the Health Resources and Services affordable care in communities at high risk for Administration (HRSA) as having: too few health disparities. They also lead to diverse patient populations, unique staffing, and 1 Health centers are also commonly referred to as community expertise – all of which make health Federally-Qualified Health Centers (FQHCs), which centers prime vehicles for community-driven refers to a Centers for Medicare and Medicaid research. Services payment designation. ● ● ● ● ● ● ● ● ● ● ● ● Health Center Patients Make Up Priority Populations Because of the mandate to serve all patients regardless of insurance or ability to pay, health Health centers currently serve over 22 million centers serve disproportionately more Medicaid medically underserved populations at high risk and uninsured patients than mainstream for acute health disparities. Nearly all health providers. Furthermore, they have extensive center patients are low income (below 200% of data on these populations that most providers the Federal Poverty Level) with 72% having do not. They currently serve 1 out of every 7 incomes at or below poverty (Figure 1). Medicaid beneficiaries in the U.S. and 1 out of Patients also tend to be members of racial and every 5 low-income uninsured.3 The following ethnic minority groups (Figure 2). At the same figures provide an overview of the populations time, 36% of health center patients are served by health centers nationally, but the uninsured and another 40% depend on characteristics of a population served by a Medicaid (Figure 3). About half of health center particular health center may differ from others patients reside in rural areas while the other and be driven by the unique characteristics of half tend to live in economically depressed the geographic setting they serve. Overall, inner city communities. In addition, they serve working with health centers offer insights and over one million homeless patients, and potential understanding of populations under- another million migrant and seasonal represented in mainstream populations. farmworkers. who experience co-morbidities and face Health centers serve populations that often compounding social determinants of health, experience high levels of chronic conditions. such as homelessness, language barriers, Top health conditions diagnosed at health poverty, and lack of social support. Few health centers are hypertension, diabetes, overweight center patients have access to innovative and obesity, depression, and asthma—many of research occurring in other practice-based which are considered priorities for research and settings. Patient and community engagement is action by Healthy People 2020 and the Agency critical so that patients are informed and are for Healthcare Research and Quality (AHRQ) as aware of opportunities to participate in Table 1 below shows.4 They also serve patients research. Table 1. Health Center Data by AHRQ Priority Populations AHRQ Priority Populations Health Center Demographics Low-Income 93% of patients are ≤200% FPL 72% of patients are ≤100% FPL Female 59% of patients are female Chronic Illness More than 40% of encounters concern a chronic illness* Rural 48% of health center grantees are in rural communities Minority 62% of patients are racial/ethnic minorities Children 32% of patients are under age 18 Elderly 7% of patients are age 65 and older Source: 2012 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. ● ● ● ● ● ● ● ● ● ● ● ● Health Centers’ Broad Array of Services and Given their patients’ broad health care needs, Staffing health centers provide services not traditionally seen in other primary care settings, such as Health centers already have much of the dental, behavioral health, pharmacy, and “foundational” infrastructure for researchers to enabling services that facilitate access to care. develop varying proposals for study. Health These include case management, outreach, center staff consist of multi-disciplinary team of translation, transportation, health education, health care professionals, who are engaged in exercise programs, nutritional assistance, quality improvement activities and who use insurance enrollment, home visitations, housing health information technology to track and assistance, job training, and support groups. evaluate performance measures. However, Health centers achieve such comprehensive few health centers have staff whose duties care through a diverse staff model that utilizes 5 solely include research ; therefore, multiple health professionals with varied skills, infrastructure often does not include research such as physicians, nurse practitioners, administrative infrastructure. physician assistants, community health workers, and case managers (Figure 5). Health center staff work in teams to ensure the Patient-Centered Medical Home (PCMH) complex health care needs of their patients are Initiative and 44% had achieved PCMH met. Health centers consistently work to recognition.6 This presents both opportunities improve their performance. As of March 2014, and challenges for engaging health centers in 73% of health centers are participating in a research. Health centers are eager to evaluate their progress in serving as PCMHs and coordinated, as well as infrastructure improving performance, particularly on the enhancements, and therefore generates many value they generate to payers, patients, and research or evaluation questions. It also means communities, but often lack dedicated research that health centers are eager to translate staff and expertise to effectively engage in proven innovations – another area in which evaluation studies. Transforming care often research can assist. requires changing how care is delivered and ● ● ● ● ● ● ● ● ● ● ● ● Health Centers’ Revenue Streams purposes. As Figure 7 below depicts, health Health centers run on tight operating margins centers’ revenue mix differs greatly from those and all rely on grants to ensure services of office-based primary care physicians. provided are comprehensive and to ensure they meet their mandate to serve all without regard Despite the mix of revenue sources, health to ability to pay. In fact, health centers centers’ operating margins are less than other currently serve 1 in 5 low-income, uninsured providers’, with some health centers running on individuals. Current funding sources make it negative operating margins. This is because difficult for most health centers to engage

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