Medical Nutrition Therapy for Adults in Health Resources & Services Administration-Funded Health Centers: A Call to Action.

Vulnerable adult populations' access to cost-effective medical nutrition therapy (MNT) for improving outcomes in chronic disease is poor or unquantifiable in most Health Resources & Services Association (HRSA)-funded health centers. Nearly 50% of the patients served at Federally Qualified Health Centers are enrolled in Medicaid; the lack of benefits and coverage for MNT is a barrier to care. Because the delivery of MNT provided by registered dietitian nutritionists is largely uncompensated, health centers are less likely to offer these evidence-based services and strengthen team-based care. The expected outcomes of MNT for adults with diabetes, obesity, hypertension, and other conditions align with the intent of several clinical quality measures of the Uniform Data System and quality improvement goals of multiple stakeholders. HRSA should designate MNT as an expanded service in primary care, require reporting of MNT and registered dietitian nutritionists in utilization and staffing data, and evaluate outcomes. Modification to the Centers for Medicare & Medicaid Services Prospective Payment System rules are needed to put patients over paperwork: HRSA health centers should be compensated for MNT provided on the same day as other qualifying visits. Facilitating the routine delivery of care by qualified providers will require coordinated action by multiple stakeholders. State Medicaid programs, Medicaid Managed Care Organizations, and other payers should expand benefits and coverage of MNT for chronic conditions, factor the cost of providing MNT into adequate and predictable payment streams and payment models, and consider these actions as part of an overall strategy for achieving value-based care.

Effect Heterogeneity in Responding to Performance-Based Incentives: A Quasi-Experimental Comparison of Impacts on Health Service Indicators Between Hospitals and Health Centers in Malawi.

Heterogeneity of effects produced by performance-based incentives (PBIs) at different levels of care provision is not well understood. This study analyzes effect heterogeneities between different facility types resulting from a PBI program in Malawi. Identical PBIs were applied to both district hospitals and health centers to improve the performance of essential health services provision. We conducted two complementary quasi-experiments comparing all 17 interventions with 17 matched independent control facilities (each 12 health centers, five hospitals). A pre- and post-test design with difference-in-differences analysis was used to estimate effects on 14 binary quality indicators; interrupted time series analysis of monthly routine data was used to estimate effects on 11 continuous quantity indicators. Effects were estimated separately for health centers and hospitals. Most quality indicators performed high at baseline, producing ceiling effects on further measurable improvements. Significant positive effects were observed for stocks of iron supplements (hospitals) and partographs (health centers). Four quantity indicators showed similar positive trend improvements across facility types (first-trimester antenatal visits, voluntary HIV-testing of couples, iron supplementation in pregnancy, vitamin A supplementation of children); two showed no change for either type of facility (skilled birth attendance, fully immunized one-year-olds); five indicators revealed different effect patterns for health centers and hospitals. In both health centers and hospitals, the largely positive PBI effects on antenatal care included resilience against interrupted supply chains and improvements in attendance rates. Observed heterogeneity might have been influenced by the availability of specific resources or the redistribution of service use.

Behavioral Health Integration into Primary Care: a Microsimulation of Financial Implications for Practices.

BACKGROUND: New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities. OBJECTIVE: To evaluate the financial impact for primary care practices of integrating behavioral health services. DESIGN: Microsimulation model. PARTICIPANTS: We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey. INTERVENTIONS: A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist. MAIN MEASURES: Net revenue change per full-time physician. KEY RESULTS: When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types. CONCLUSIONS: New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.

Innovation in the safety net: integrating community health centers through accountable care.

BACKGROUND: Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers. OBJECTIVE: This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers. DESIGN: Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013). PARTICIPANTS: One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs. MAIN MEASURES: Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software. KEY RESULTS: Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise. CONCLUSIONS: A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.

Rehabilitation for the management of knee osteoarthritis using comprehensive traditional Chinese medicine in community health centers: study protocol for a randomized controlled trial.

BACKGROUND: It is becoming increasingly necessary for community health centers to make rehabilitation services available to patients with osteoarthritis of the knee. However, for a number of reasons, including a lack of expertise, the small size of community health centers and the availability of only simple medical equipment, conventional rehabilitation therapy has not been widely used in China. Consequently, most patients with knee osteoarthritis seek treatment in high-grade hospitals. However, many patients cannot manage the techniques that they were taught in the hospital. Methods such as acupuncture, tuina, Chinese medical herb fumigation-washing and t'ai chi are easy to do and have been reported to have curative effects in those with knee osteoarthritis. To date, there have been no randomized controlled trials validating comprehensive traditional Chinese medicine for the rehabilitation of knee osteoarthritis in a community health center. Furthermore, there is no standard rehabilitation protocol using traditional Chinese medicine for knee osteoarthritis. The aim of the current study is to develop a comprehensive rehabilitation protocol using traditional Chinese medicine for the management of knee osteoarthritis in a community health center. METHOD/DESIGN: This will be a randomized controlled clinical trial with blinded assessment. There will be a 4-week intervention utilizing rehabilitation protocols from traditional Chinese medicine and conventional therapy. Follow-up will be conducted for a period of 12 weeks. A total of 722 participants with knee osteoarthritis will be recruited. Participants will be randomly divided into two groups: experimental and control. Primary outcomes will include range of motion, girth measurement, the visual analogue scale, and results from the manual muscle, six-minute walking and stair-climbing tests. Secondary outcomes will include average daily consumption of pain medication, ability to perform daily tasks and health-related quality-of-life assessments. Other outcomes will include rate of adverse events and economic effects. Relative cost-effectiveness will be determined from health service usage and outcome data. DISCUSSION: The primary aim of this trial is to develop a standard protocol for traditional Chinese medicine, which can be adopted by community health centers in China and worldwide, for the rehabilitation of patients with knee osteoarthritis. CLINICAL TRIALS REGISTRATION: ChiCTR-TRC-12002538.

Health reform's impact on federally qualified community health centers: the unintended consequence of increased Medicaid enrollment on the primary care medical home.

The impact of recently passed health reform legislation may cause substantial changes in community health center (CHC) operations. The new legislation provides federal funding for center expansion, increased Medicaid enrollment, enhanced Medicare payments, training to increase primary care providers, and incentives to develop CHCs as accountable care organizations. Health reform could place CHCs in a vulnerable financial situation. Newly insured patients may seek care at private providers, whereas CHCs are left caring only for the uninsured. Thus, CHCs are unable to benefit from enhanced insurance payments needed to offset care given to the uninsured. Conversely, if CHCs participate in developing comprehensive care networks for low-income populations by strengthening referral networks, developing primary medical care homes and accountable care organizations, and investing in infrastructure, then health center medical care will be a desired option for the newly insured, and a robust safety-net system may result.

Community dental clinics: providers' perspectives.

OBJECTIVES: Not-for-profit community dental clinics attempt to address the inequities of oral health care for disadvantaged communities, but there is little information about how they operate. The objective of this article is to explain from the perspective of senior staff how five community dental clinics in British Columbia, Canada, provide services. METHODS: The mixed-methods case study included the five not-for-profit dental clinics with full-time staff who provided a wide range of dental services. We conducted open-ended interviews to saturation with eight senior administrative staff selected purposefully because of their comprehensive knowledge of the development and operation of the clinics and supplemented their information with a year's aggregated data on patients, treatments, and operating costs. RESULTS: The interview participants described the benefits of integrating dentistry with other health and social services usually within community health centres, although they doubted the sustainability of the clinics without reliable financial support from public funds. Aggregated data showed that 75% of the patients had either publically funded or no coverage for dental services, while the others had employer-sponsored dental insurance. Financial subsidies from regional health authorities allowed two of the clinics to treat only patients who are economically vulnerable and provide all services at reduced costs. Clinics without government subsidies used the fees paid by some patients to subsidize treatment for others who could not afford treatment. CONCLUSIONS: Not-for-profit dental clinics provide dental services beyond pain relief for underserved communities. Dental services are integrated with other health and community services and located in accessible locations. However, all of the participants expressed concerns about the sustainability of the clinics without reliable public revenues.

Nurse-midwives in federally funded health centers: understanding federal program requirements and benefits.

Midwives are working in federally funded health centers in increasing numbers. Health centers provide primary and preventive health care to almost 20 million people and are located in every US state and territory. While health centers serve the entire community, they also serve as a safety net for low-income and uninsured individuals. In 2010, 93% of health center patients had incomes below 200% of the Federal Poverty Guidelines, and 38% were uninsured. Health centers, including community health centers, migrant health centers, health care for the homeless programs, and public housing primary care programs, receive grant funding and enjoy other benefits due to status as federal grantees and designation as federally qualified health centers. Clinicians working in health centers are also eligible for financial and professional benefits because of their willingness to serve vulnerable populations and work in underserved areas. Midwives, midwifery students, and faculty working in, or interacting with, health centers need to be aware of the regulations that health centers must comply with in order to qualify for and maintain federal funding. This article provides an overview of health center regulations and policies affecting midwives, including health center program requirements, scope of project policy, provider credentialing and privileging, Federal Tort Claims Act malpractice coverage, the 340B Drug Pricing Program, and National Health Service Corps scholarship and loan repayment programs.

Primary care and public health activities in select US health centers: documenting successes, barriers, and lessons learned.

OBJECTIVES: We examined primary care and public health activities among federally funded health centers, to better understand their successes, the barriers encountered, and the lessons learned. METHODS: We used qualitative and quantitative methods to collect data from 9 health centers, stratified by administrative division, urban-rural location, and race/ethnicity of patients served. Descriptive data on patient and institutional characteristics came from the Uniform Data System, which collects data from all health centers annually. We administered questionnaires and conducted phone interviews with key informants. RESULTS: Health centers performed well on primary care coordination and community orientation scales and reported conducting many essential public health activities. We identified specific needs for integrating primary care and public health: (1) more funding for collaborations and for addressing the social determinants of health, (2) strong leadership to champion collaborations, (3) trust building among partners, with shared missions and clear expectations of responsibilities, and (4) alignment and standardization of data collection, analysis, and exchange. CONCLUSIONS: Lessons learned from health centers should inform strategies to better integrate public health with primary care.

Creating an effective and efficient publicly sponsored health care delivery system.

An effective and efficient publicly sponsored health care delivery system can increase access to care, improve health care outcomes, and reduce spending. A publicly sponsored health care delivery system can be created by integrating services that are already federally subsidized: community health centers (CHCs), public and safety-net hospitals, and residency training programs. The Patient Protection and Affordable Care Act includes measures that support primary care generally and CHCs in particular. A publicly sponsored health care delivery system combining primary care based in CHCs with safety-net hospitals and the specialists that serve them could also benefit from incentives in the Patient Protection and Affordable Care Act for the creation of accountable care organizations, and reimbursement based on quality and cost control.

Maximizing the value of a breast center.

This article focuses on the value and benefit of a Breast Center to an organization by identifying the best ways to maximize their contribution in order to create and sustain a financially viable, clinically respected and community-oriented Breast Center. The goal of the Breast Center is to ultimately benefit the community and the hospital's Comprehensive Cancer Program as a whole. The value propositions are divided into three areas that have positive impacts to the program and hospital, collectively. These value propositions are: 1. Financial Value e identified values of the Breast Center that contribute to the bottom line - or Return on Investment (ROI) - of the Cancer Program. 2. Clinical Quality Values - identified values of the Breast Center that improve the quality of care and outcomes of the patients. 3. Intangibles Values - identified values of the Breast Center that connect to the community and women that is invaluable to the Cancer Program.

Prescription pattern for treatment of hemorrhoids under the universal coverage policy of Thailand.

The Universal Coverage Policy (UCP) or "30 Baht Scheme" was launched in Thailand in 2001. The policy caused a cutback in the budgets of all public hospitals and health service centers. Traditional medicine was then viewed as an alternative to save costs. This study examines whether this had any influence on hemorrhoid treatment prescription patterns, ratio of traditional/modern medicine, or the cost of hemorrhoid treatment after the UCP was implemented at a community hospital. The traditional medicine prescribed was Petch Sang Kart and the modern alternative was Proctosedyl. All hemorrhoid prescriptions at a community hospital from October 2000 to January 2003 were surveyed. Segmented Regression Analysis was applied to evaluate prescription trends, the ratios between the types of medicine, and the hemorrhoid treatment cost. A total of 256 prescriptions were analyzed. The average number of traditional medicine prescriptions per month were more than modern medicine (41 versus 16). During the study period, the trend of modern medicine use and the treatment cost was decreased (p < 0.01). The ratio of traditional/modern medicine increased 0.2 times (p = 0.02).

Denver Health: a model for the integration of a public hospital and community health centers.

Two major pillars of the United States' safety net system are urban public hospitals and community health centers. Their common mission is to care for the uninsured and other vulnerable populations. However, in most communities these important components of the safety net remain organizationally and functionally separate, which inhibits the continuum of care and creates substantial inefficiencies. Denver Health is a long-standing vertically and horizontally integrated system for vulnerable populations. The integration benefits the patient and the system and serves as a model for the U.S. safety net. This paper outlines the benefits of integration to the patient, provider, and health system, using data from the National Association of Public Hospitals and Health Systems, the Bureau of Primary Health Care, and Denver Health.

Community health center-led networks: cooperating to compete.

The primary mission of community health centers (CHCs) is to provide primary and preventive healthcare for the underserved and vulnerable populations, including the uninsured, underinsured, and Medicaid beneficiaries. Economic and regulatory challenges have placed these safety net providers in a precarious position, forcing some to respond using cooperative strategies. This article focuses on seven CHC-led networks, delineating their integrative efforts in the core areas of managed care, clinical, administrative, information, and finance. Interviews with key representatives from each network highlight the networks' accomplishments and the critical success factors and outcomes of their integrative efforts. Several underlying themes emerged from this study that are consistent with findings of previous studies conducted in other organizational settings. Specifically participants in CHC-led networks cite the following factors as contributors to success: reciprocity, communication, trust, and long-standing relationships among key individuals. This is the first study to provide a rich depiction of CHC network activities.

Reforming Ontario's primary health care system: one step forward, two steps back?

In Ontario, one-third of the provincial budget is spent on treatment-oriented, institutionally based medical care. Urgently needed, some critics say, is a shift toward less costly, prevention-oriented, community-based care informed by a nonreductionist approach to health planning. In this regard, Community Health Centres (CHCs) have long been advocated as the most effective way to reform the province's primary health care system. At present, however, Ontario has only 56 CHCs. This article examines factors that gave rise to the implementation of CHCs during the 1970s, their slow growth across the province during the 1980s, and their relatively rapid expansion during the early 1990s. In 1995, the newly elected Progressive Conservative government decided to freeze funding for this innovative program. The author argues that the state's latest plan for "reforming" the province's primary health care system is destined to repeat the mistakes of the past.