Advancing Virtual at-Home Care for Community Health Center Patients Using Patient Self-Care Tools, Technology, and Education.

Introduction: Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers. Objective: This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures. Methods: A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared. Results: A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p<0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p<0.001). Conclusion: Health centers applying the Value Transformation Framework's organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.

Patient and Staff Satisfaction and Experience While Transforming Health Center Systems.

Introduction: Patient satisfaction and experience are important measures of overall quality of care. In 2017, the National Association of Community Health Centers (NACHC) launched an initiative to facilitate changes across organizational systems within Federally Qualified Health Centers (FQHCs) with the goal of improving value-driven care. Methods: NACHC worked with eight health centers, four in Georgia and four in Iowa, along with their state Primary Care Associations, to apply the Value Transformation Framework (VTF). This framework distills evidence-based practices into practical knowledge for goal-driven systems change. It provides actionable steps to help health centers reach value-driven goals of improved health outcomes, improved patient and staff experience, reduced costs, and improved equity (referred to as the Quintuple Aim goals). This paper reports on the patient and staff experience when applying VTF systems changes to improve colorectal cancer screening rates. Results: Patient and staff satisfaction and experience remained highly rated even after extensive organizational changes were implemented as part of this project. Implementation of a systems-approach to organizational change, through application of the VTF, did not negatively impact patient or staff experiences. Conclusion: Patient and staff satisfaction and experience were positive despite the application of the VTF and systems-wide organizational changes. These experience results were alongside improved cancer screening rates, as observed from full project results. Investigators are encouraged that the application of systems change using the VTF may result in the achievement of Quintuple Aim goals without disrupting the experience of patients and staff. Investigators recommend continued exploration of this transformation approach.

Applying the Value Transformation Framework in Federally Qualified Health Centers to Increase Clinical Measures Performance.

INTRODUCTION: The transition in health care from a volume-based to value-based model of care, combined with pressures brought about by the COVID-19 pandemic, makes the need for efficiency and coordination of the health center system imperative. The Value Transformation Framework (VTF), developed with health centers in mind, provides an organizing framework to support transformation of infrastructure, care delivery, and people systems. METHODS: NACHC applied the VTF within a cohort of health centers across the country to drive systems change and improve performance on measures of clinical care. RESULTS: A comparison of health centers "participating" in application of the VTF relative to "nonparticipating" health centers nationally showed improvement during 3 years of program implementation. Significant differences ( p < .05) favoring health centers who participated were noted for screening of colorectal cancer ( p < .001), depression ( p < .001), hypertension ( p < .001), obesity ( p = .001), and cervical cancer ( p = .011). Performance for diabetes control also favored participating programs, although the difference did not quite reach significance ( p = .45). CONCLUSIONS: Applying a systems approach, organized by the VTF, with evidence-based interventions and deployed in a learning community, can result in improved performance across multiple measures of clinical care.

The Value Transformation Framework: Applied to Diabetes Control in Federally Qualified Health Centers.

INTRODUCTION: Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications. OBJECTIVE: By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers' infrastructure, people systems and care delivery systems. METHODS: Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project. RESULTS: During the one-year intervention (January 2017-December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7-70.4%) in January to 27.5% (range, 13.6-37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level. CONCLUSION: A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.

The Value Transformation Framework: An Approach to Value-Based Care in Federally Qualified Health Centers.

BACKGROUND: With the transition toward value-based care, health care organizations have a business imperative to simultaneously focus on improved health outcomes, improved patient and staff experience, and reduced costs (the Quadruple Aim). For federally qualified health centers-which provide care to some of nation's most vulnerable populations-balancing the complex task of systems change in the face of overwhelming volumes of information and best practices is challenging and can be supported through a guiding framework. PURPOSE: This need for synthesis and translation of evidence in an actionable and practical way led to the design of a model for health center systems change. This article describes the development process and defines the resulting conceptual framework. METHODS: Deployed a four-step process between 2016 and 2018 to develop and test a framework for value transformation in health centers. RESULTS: NACHC's Quality Center developed the Value Transformation Framework to guide health center systems change toward high value care. The framework identifies 15 change areas across three Domains: infrastructure, care delivery, and people and summarizes evidence-based action steps within the change areas. CONCLUSIONS: The framework shows promise in supporting health center efforts to adapt, transform, and balance competing demands as they advance value-based models of care.

Colorectal Cancer: Applying the Value Transformation Framework to increase the percent of patients receiving screening in Federally Qualified Health Centers.

BACKGROUND: Colorectal cancer is the second leading cause of cancer death in the U.S. and third-most common cancer in both men and women. Colorectal cancer screening (CRCS) rates remain low, particularly among vulnerable patients receiving care at federally qualified health centers. Through its Value Transformation Framework, the National Association of Community Health Centers provides a systematic approach to improving CRCS by transforming health center infrastructure, care delivery, and people systems-to improve health outcomes, patient and staff experiences, and lower costs (Quadruple Aim). METHODS: We combined the Value Transformation Framework, evidence-based CRCS interventions, and the Learning Community Model to drive system improvements and implement evidence-based practices. Multi-disciplinary teams at 8 health centers in Georgia and Iowa participated for 1-year with Primary Care Association support. RESULTS: Pre-/post- 1-year-intervention data showed, within health centers, raw percentage of eligible patients screened for CRC increased from 33.2% (13.5%-61.7%) in January 2017 to 46.5% (14.2%-81.5%) in December 2017, with an overall 13.3 percentage point average increase. This translates into an average increase of 3.3 (95% CI: 1.7, 5.0) eligible patients screened per month per health center over the year or 317 additional patients meeting CRCS guidelines. Specific interventions associated with higher CRCS rates included standing orders, sharing performance data, and electronic health record alerts. CONCLUSION: Findings support a three-pronged approach for improving CRCS: The Value Transformation Framework's evidence-based recommendations, with actionable CRC interventions, offered in a learning community. These results guide methodological approaches to improving CRCS in health centers through a multi-level, multi-modality quality improvement and transformation approach.

Routine rapid HIV screening in six community health centers serving populations at risk.

BACKGROUND: In 2006, to increase opportunities for patients to become aware of their HIV status, the Centers for Disease Control and Prevention released updated guidelines for routine, opt-out HIV screening of adults, adolescents, and pregnant women in healthcare settings. To date, there are few documented applications of these recommendations. OBJECTIVE: To measure the impact of application of the guidelines for routine screening in health centers serving communities disproportionately affected by HIV in the southeastern US. DESIGN: A multi-site program implementation study, describing patients tested and not tested and assessing changes in testing frequency before and after new guidelines were implemented. PARTICIPANTS: All patients aged 13 to 64 seen in participating health centers. INTERVENTIONS: Routine rapid HIV screening in accord with CDC guidelines. MEASUREMENTS: The frequency of testing before and after routine screening was in place and demographic differences in offering and receipt of testing. MAIN RESULTS: Compared to approximately 3,000 patients in the year prior to implementation, 16,148 patients were offered testing with 10,769 tested. Of 39 rapid tests resulting in preliminary positives, 17 were newly detected infections. Among these patients, 12 of 14 receiving referrals were linked to HIV care. Nineteen were false positives. Younger patients, African Americans and Latinos were more likely to receive testing. CONCLUSIONS: By integrating CDC-recommended guidelines and applying rapid test technology, health centers were able to provide new access to HIV testing. Variation across centers in offering and receiving tests may indicate that clinical training could enhance universal access.