1. HRSA , Health Centers, and
Managing Workforce
Challenges
November 2, 2013
Nick Zucconi
Deputy Regional Administrator
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Regional Operations, Denver
2. HRSA Priorities
ďź Strengthen the Primary Care Workforce to
Better Meet the Health Needs of the Nation
ďź Improve Access to High Quality Primary Care
Services, Integrated with Public and
Population Health
ďź Strengthen HRSAâs Organizational and
Technology Infrastructure, Workforce, and
Workplace Climate
4. The People We Serve
⢠About 16,750 safety net providers participate in the
340B drug discount program.
⢠Over 500,000 people living with HIV/AIDS receive Ryan
White services. Two-thirds are racial or ethnic minorities.
⢠34 million women, infants, children, and adolescents
benefit from maternal and child health programs.
⢠More than 8,650 National Health Service Corps clinicians
are working in underserved areas.
⢠19.5 million patients served through health centers.
5. HRSA in Colorado
⢠In fiscal year 2012, HRSA awarded $153M to
45 grantees
â 59% = Primary Care
â 19% = Ryan White HIV/AIDS
â 12% = Maternal and Child Health
â 7% = Health Professions
â 2% = Rural Health
â <1% = Clinician Recruitment
â <1% = Health Care Systems
6. Health Center Fundamentals
1. Located in or serve a high need community
(designated Medically Underserved Area).
2. Governed by a community board composed of a
majority of patients representing the population
served.
3. Provide comprehensive primary health care services
as well as supportive services (education, translation
and transportation, etc.) to promote access to care.
4. Provide services available to all with fees adjusted
based on ability to pay.
5. Meet federal program requirements regarding
administrative, clinical, and financial operations.
7. Health Center Program
National Grantee Overview-CY 2012
21.1 Million Patients
⢠93% Below 200% Poverty
â˘
â˘
â˘
â˘
â˘
Grantees Serve
All Ages
36% Uninsured
62% Racial/Ethnic Minorities
1,121,037 Homeless Individuals
903,089 Farmworkers
219,220 Residents of Public Housing
65 & Under 5
up
11%
7%
5 to 12
13%
25 to 64
51%
Grantees Revenue Sources
ARRA Grants
2%
BPHC Grants
18%
Other Federal
Grants
3%
â˘
Medicaid
38%
State /
Local/Other
17%
Medicare
6%
Self-Pay
6%
Other 3rd Party
7%
â˘
â˘
â˘
â˘
13 to 17
8%
18 to 24
10%
1,198 Grantees with 8,900+
Service Sites
83.8 Million Patient Visits
Over 148,000 Staff
10,400+ Physicians
7,500+ NPs, PA, & CNMs
Other Public
Insurance
3%
Source: Uniform Data System, 2012, Service Sites: HRSA Electronic Handbooks
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8. Health Center Program Growth:
National Impact 2008 - 2012
Sites
21
Jobs
10
Thousands
22
Thousands
Millions
Patients
9.5
160
150
9
140
8.5
130
8
120
7.5
110
7
100
20
19
18
17
2008 2009 2010 2011 2012
2008 2009 2010 2011 2012
2008 2009 2010 2011 2012
2008
2009
2010
2011
2012
Growth from 2008-2012
(% Increase)
Patients
17,122,535
18,753,858
19,469,467
20,224,757
21,102,391
3,979,856 (23.2%)
Sites
7,518
7,892
8,156
8,501
8,979
1,461 (19.4%)
Jobs
113,059
123,012
131,660
138,403
148,245
35,186 (31.1%)
Source: Uniform Data System, 2008-2012 and HRSA Electronic Handbooks
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10. Health Center Program
Colorado Overview-CY 2012
494,000 Patients
⢠95% Below 200% Poverty
⢠38% Uninsured
⢠64% Racial/Ethnic Minorities
⢠30,500 Homeless Individuals
⢠13,250 Farmworkers
⢠2,000 Residents of Public Housing
18 Community Health Centers
⢠152 Service Sites
⢠In 2012, Colorado CHCs provided more than 2
million medical, dental, and mental health visits
⢠Colorado CHCs care for:
⢠1/3 of all Medicaid enrollees
⢠1/4 of all Childrenâs Health Insurance Program
(CHIP) enrollees
⢠1/3 of all the stateâs low-income uninsured
Source: Uniform Data System, 2012, Service Sites: HRSA Electronic Handbooks
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11. What are the challenges?
Summary of Major Issues
â˘
â˘
â˘
â˘
Workforce recruitment and retention
Too few people; those we have, need help
Geographic and specialty maldistribution
Competing priorities for providers & patients
12. What We Do Now
Quality Strategy
Better Care â Healthy People & Communities â Affordable Care
Strategy Implementation
INTEGRATED
HEALTH SYSTEM
Priorities & Goals
1.
Implementation of QI/QA Systems
All Health Centers fully implement their
QI/QA plans
2.
Adoption and Meaningful Use of EHRs
All Health Centers implement EHRs
across all sites & providers
3.
Patient-Centered Medical Home
Recognition
All Health Centers receive PCMH
recognition
4.
Improving Clinical Outcomes
All Health Centers meet/exceed
HP2020 goals on at least one UDS
clinical measure
5.
Workforce/Team-Based Care
All Health Centers are
employers/providers of choice and
support team-based care
12
1. Programs/Policies
2. Funding
3. Technical Assistance
INTEGRATED
SERVICES
4. Data/Information
5. Partnerships/Collaboration
COMPREHENSIVE
SERVICES
ACCESS
13. Current Program Impact:
Key National Indicators
% of Health Centers with EHR Implementation (2012)
ď§ 79% have EHRs at all sites used by all providers
ď§ 11% have EHRs at some sites used by some providers
% of Health Centers Achieving Patient-Centered Medical Home Recognition
(as of August 2013)
ď§ 80% of all health centers are participating in Patient-Centered Medical
Health Home Initiatives (PCMHHI) and nearly 29% have achieved
Patient-Centered Medical Home (PCMH) recognition
% of Health Center Meeting/Exceeding Healthy People 2020 Goals (2012):
ď§ 59% Meet/Exceed Hypertension Control Goal of 61%
ď§ 11% Meet/Exceed Diabetes Control (HbA1c â¤9) Goal of 84%
ď§ 37% Meet/Exceed Early Entry into Prenatal Care Goal of 78%
ď§ 61% Meet/Exceed Low Birthweight Goal of 7.8%
Individual health center profiles with performance data are now
available to the public on the HRSA web site. See:
http://bphc.hrsa.gov/uds/datacenter.aspx?q=d&year=2012
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14. Percentage of EHR Adoption by State
2011
Source: Uniform Data System, 2011
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15. Health Center EHR Adoption
National and Colorado 2012
100%
90%
80%
11%
21%
2015 Goal:
100% of
Health Centers
use EHR at All
Sites
70%
60%
50%
40%
79%
79%
30%
2012 Goal:
50% of Health
Centers use
EHR at All
Sites
20%
EHR at Some
10%
Sites
EHR at All
0%
Sites
National
Source: Uniform Data System, 2012
CO State
15
17. 2013 Health Center PCMH Recognition
National and Colorado
100%
90%
80%
PCMHHI
Participants
PCMH
80%
70%
59%
60%
65%
2014 Goal:
40% of Health
Centers
Recognized
as PCMH
50%
40%
30%
Recognized
29%
2013 Goal:
25% of Health
Centers
Recognized
as PCMH
20%
10%
0%
National
Data as of August 16, 2013
PCMH Recognized Includes: NCQA, Joint Commission, and AAAHC
CO State
17
18. 2012 National and Colorado Health Center
Performance and Healthy People 2020 Goals
100%
Percentage of Health Centers Meeting or
Exceeding Healthy People 2020 Goals
90%
80%
70%
60%
61%
59%
59%
50%
50%
37%
40%
30%
20%
10%
11%
6%
46%
2014
Goal:
20+% of
Health
Centers
Meet or
Exceed
HP 2020
Goals
0%
Hypertension Control
Diabetes Control
National
CO State
Early Entry to Prenatal Care
Low Birthweight
18
Source: 2012 UDS and Healthy People 2020
19. 2012 Colorado
Range of Clinical Performance
High
Low
CO State
Average
National
Average
Diabetes Control
84%
57%
70%
70%
Timely entry into Prenatal Care
100%
59%
72%
70%
Hypertension Control
79%
47%
65%
64%
Low Birth Weight
0%
14%
8%
7%
Childhood Immunizations
79%
11%
33%
42%
Cervical Cancer Screening
84%
14%
62%
57%
Asthma Therapy
94%
50%
61%
73%
Source: Uniform Data System, 2012.
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21. Quality Strategy Implementation
Primary Care Associations
⢠Colorado Community Health Network (CCHN) is the
membership association for the 18 federally funded
Community Health Centers.
⢠CCHN:
1. Educates policy makers and stakeholders about
the unique needs of CHCs and their patients;
2. Provides resources to ensure that CHCs are
strong organizations; and
3. Supports CHCs in maintaining the highest
quality care.
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22. Quality Strategy Implementation
Primary Care Office (PCO)
The Colorado State Department of Public Health and
Environment (CDPHE) serves as the Primary Care
Office in the State.
⢠Technical Assistance to Organizations and
Communities Seeking to Expand Access to
Primary Care for Underserved Populations
⢠Assessment of Needs and Sharing Data
⢠Workforce Development for the NHSC and
Safety Net and Health Center Network
⢠Shortage Designation Applications and Updates
http://www.colorado.gov/cs/Satellite/CDPHEPSD/CBON/1251618793013
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23. Quality Strategy Implementation
State Office of Rural Health
The Colorado Rural Health Center (CRHC) works with federal,
state and local partners to offer services and resources to rural
healthcare providers, facilities and communities:
⢠provides recruitment and retention services and connects
communities with loan repayment options for their
providers;
⢠supplies organizations with funds and equipment, such as
workforce-enhancing loan repayment or scholarships;
Federally-granted medical equipment; or technical
assistance grants to rural hospitals and communities.
⢠convenes workshops, training programs, and technical
assistance to facilities and communities, such as coding,
billing, quality improvement, and compliance assistance.
http://www.coruralhealth.org/
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24. Quality Strategy Implementation
Area Health Education Center
The Colorado Area Health Education Centers were established as
an academic-community partnership involving the University of
Colorado Denver and six community-based nonprofit regional
AHEC offices, each serving a designated region of the state.
The AHEC works to build state-wide network capacity and
strengthen academic-community linkages in four areas:
⢠Health Careers and Workforce Diversity
⢠Health Professions Student Education
⢠Health Professions Continuing Education
⢠Public Health and Community Education
http://www.ucdenver.edu/life/services/ahec/Pages/index.aspx
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25. Nick Zucconi
Deputy Regional Administrator
Health Resources and Services Administration
Office of Regional Operations - Denver
303-844-7879
Nicholas.zucconi@hrsa.hhs.gov
Hinweis der Redaktion
In the past few years, health centers have also achieved significant growthOverall, since the beginning of 2009, health centers have increased the total number of patients served 17.1 million to 21.1 million annually.Health centers have furthered their national impact not only in terms of increased numbers of patients served, but also by adding sites and creating essential jobs within their communities. In fact, health centers have added more than 25,200 jobs over the last three years.
HRSA-funded health centers, as a whole now constitute one of the largest primary care networks in the country â a true national presence
Ensuring an appropriate and adequate health care professional workforce is challenging on many levels and health centers are not an exception here. Some of the major issues we face are workforce recruitment and retention, too few people and those we have need help, geographic and specialty maldistribution, and competing priorities for providers and patients.
All of our efforts aimed at meeting these challenges are framed by our quality strategy. Our goals are consistent with the triple aim of better care, healthy people and communities, and affordable care. In achieving our strategic goals BPHCâs focus continues to be on positioning health centers within the larger national goal of moving towards a truly Integrated Health System-one in which coordination and integration of patient information and services among and across Health Centers and other community-based health care providers is the norm-and not the exception. In order to get to this point, we must continue to strengthen the Health Center Programâs foundation of Access.And of course, we want this to be access to Comprehensive Services-the full scope of high quality primary health services, including dental, behavioral health, and enabling services. Once we have assured access and comprehensive services, we can move upwards towards implementing Integrated Services by assuring health center patients have a true patient-centered medical home that ultimately, is part of an overall more effective Integrated Health System.All HRSA/BPHC quality related activities are IMPLEMENTED through one or several of the FIVE elements or mechanisms across the top of the slide (published policies, funding opportunities, Onsite TA Visits, etc.) in order to support and promote the PRIORITIES AND GOALS on the RIGHT. Our five priority quality goals are interrelated and all have an impact on workforce and patientâs ability to be receive the right care at the right time:Implementation of QI/QA SystemsAdoption and Meaningful Use of EHRsPatient-Centered Medical Home RecognitionImproving Clinical OutcomesWorkforce/Team-Based Care
Electronic Health Records adoption and Patient-centered Medical Home recognition which are key transformative tools in realizing the HRSA goals of increased quality, improved access to care, and reduced health disparities. Slide Data Notes:Clinical Performance Measure and EHR Implementation Data are from the 2012 UDS.PCMH Recognition Data:NCQA Data is as of 8/13 and includes those recognized in the HRSA PCMHHI and those who sought recognition independently. Accreditation Data is as of 8/1/13 (provided quarterly) % of PCMHHI participants is based on the % of grantees that have been moved forward to NCQA to receive recognition. NCQA recognized grantees at the site level, Accreditation recognizes the entire organization.
Even before ARRA and Meaningful Use, HRSA has viewed HIT as central to quality improvement in health centers, and has been encouraging them to adopt and use health IT for quality improvement and cost efficiencies since the 1990âs.We see HIT as a key transformative tool in supporting and realizing the HRSA and Health Center Program goals of increased quality, improved access to care, and reductions in health disparities.It is no surprise therefore that health centers remain national leaders in electronic health records adoption and service delivery transformation.BPHCâs 2012 goal is to have at least 50% of grantees with EHR adopted at all sites and in use by all providers â and we have already well surpassed this internal goal.As an example, letâs look at the statewide of EHR adoption in CO â 79% of health centers in CO have implemented EHR at all of their sites and 21% have implemented EHR at some sites.
PCMH recognition is also an HHS level priority and in support of this BPHC has set a related 2013 goal to have 25% of grantees with at least one site recognized: As of August, 2013, 29% of all grantees have achieved PCMH Recognition. For comparison, 59% of health centers in CO are participating in one of the HRSA PMCH initiatives and 65% have achieved PCMH recognition (some health centers may have achieved recognition outside of a HRSA-sponsored initiative)While PCMH adoption is a newer area for all primary care providers-we are pleased at the swift adoption and increase in efforts across the Health Center Program.Â
Finally - the most important impact of the Health Center Program is of course to improve the health outcomes of health center patients. Utilizing the key transformative quality tools of electronic health records and the patient-centered medical home model-we must work towards achieving goals of improved performance for all health centers on these HRSA/BPHC Required Clinical Performance Measures reported annually in UDS.Let me first focus on how the HRSA/BPHC Required Clinical Performance Measures compare to current national averages as well as to Healthy People 2020 goals. Hypertension Control: The HP2020 goal is that at least 61% of hypertensive patients have their BP under control. Nationally, across the US, only 44% of hypertensive patients actually have their BP under control while nationally, across all health centers, the average rate of hypertension control is 64%, which is slightly higher than the HP2020 goal. So health centers are doing better than the US in general, and many health centers are already achieving the HP2020 goal.Specifically, in 2012, 59% of all health centers already met or exceeded the Healthy People 2020 goal for hypertension. Diabetes Control: The HP2020 goal is that at least 85% of diabetic patients have hemoglobin levels under 9%. Nationally, across the US, 84% of diabetic patients are under control. This one of the hardest of the clinical performance measures to move, and nationally, across all health centers, the average rate of diabetes control is 70%, which is both below the HP2020 goal and national averages.Given these challenges, only 11% of all health centers met or exceeded the HP 2020 goal for diabetes in 2012.Early Entry into Prenatal Care: The HP2020 goal is that at least 78% of pregnant women will receive prenatal care beginning in the first trimester. Nationally, across the US, about 71% of percent of women delivering a live birth received prenatal care beginning in the first trimester (2007 data) while nationally, across all health centers, the percentage of pregnant women receiving early prenatal care is 70%, just slightly below the national average. Clearly there is room for improvement both nationally and across the Health Center Program in order to achieve the HP2020 goal of 78%. However it is important to note that, 37% of all health centers already met or exceeded the Healthy People 2020 goal for early entry into prenatal care in 2011. Low Birthweight: The HP2020 goal is to reduce the rate of low birthweight nationally to 7.8%. Currently, across the US, nearly 8.2% of babies are born at low birthweight, while across all health centers, the low birthweight rate is quite a bit lower at 7.8%, So not only are health centers already doing better than the US at reducing poor birth outcomes, on average the program has also already exceeded the HP2020 goal.Specifically, an impressive 61% of all health centers already met or exceeded the Healthy People 2020 goal for reductions in low birthweight in 2012.The right side of the graph shows the percentage of health centers in CO meeting or exceeding HP 2020 goals in these 4 areas (HTN control, DM control, early entry to prenatal care, and LBW).
We know that all this work canât be done alone and encourage health centers to collaborate with national, state, and local partners in leveraging partnerships to achieve mutual goals. Health centers are involved with many different national initiatives with the White House (National HIV/AIDS strategy, Letâs Move), and other federal agencies (Million Hearts Initiative , CDC, National Prevention Strategy, Text4baby) etc. Health centers also partner with PCAs, PCOs, and state Medicaid offices as well as local partners such as health center controlled networks (HCCN), other safety net providers, hospitals, and community based organizations.