Community collaborations: 6 areas of focus for hospital and federally qualified health center partnerships

In the emerging landscape of accountable care, with its emphasis on population health and preventive care, healthcare services will be delivered not only through private physicians and hospitals, but also in collaboration with community providers.

Community health centers (CHCs) are uniquely positioned to be an important partner for hospital systems as healthcare delivery systems seek out new methods to improve health outcomes. It is imperative for hospitals and health centers to understand how to form collaborations, the role they should play in these collaborations and what is needed to maximize the benefits of collaborating with federally qualified health centers (FQHCs) to create integrated delivery models of care that provide a coordinated continuum of services to targeted patient populations.

By collaborating and working in partnership with FQHCs, hospital systems will be better positioned to provide high-quality, cost-effective and patient-centered care. Here are six areas of focus for hospital/FQHC partnerships.

1. Completing and implementing a Community Health Needs Assessment (CHNA). It is important to break down communication barriers between hospital systems and FQHCs, and engage leaders in both organizations to collaborate. If these organizations must complete a CHNA, why not work together to identify and prioritize the health needs of the community?

When writing the CHNA, it is important to take every organizations' needs and goals into account. The partnership should set goals that are focused and well-defined, and therefore inspire community engagement and support. By collaborating, hospitals and FQHCs can obtain leadership commitment at the state, community and provider levels as the organizations will have integrated strategic and business planning, and shared quality improvement programs. Implementation strategies should describe what actions each organization will take, the impact of those actions and then the resources needed from the organizations to implement the initiatives.

2. Create a network of sustainable FQHC medical homes. As demonstrated in this infographic on hospital-FQHC partnerships, FQHC visits are projected to account for approximately 40 million patients in 2015. This number will continue to rise as more patients are establishing medical homes.

As an increasing number of hospitals across the country take leadership roles in their community and think outside of their institutional walls, it is imperative they leverage the existing FQHC primary care network, which consists of approximately 9,200 delivery sites. Cross-sector collaborations are happening across the country. As was reported by hospital leaders at the 2015 Association for Community Health Improvement (ACHI) annual conference, hospitals are moving from a compliance mentality to a transformational commitment. It is time to collaborate and create healthier and more equitable communities.

One method of collaboration we have seen work successfully involves hospitals assisting with funding for capital needs and helping build more FQHC clinics by donating lease space. Some hospitals have found value in placing an FQHC clinic near or on their hospital campus to ensure patients are appropriately seen in a primary care setting and not in the emergency room (ER) or inpatient setting.

"When forming collaborations, it is important for each agency to understand 'what is in it for them,'" said Margaret Brennan, president and CEO of Community Health Centers in Florida, in an interview with the authors of this column. "To stay true to the mission, and to understand that together, we will all be contributing to improving access to services and health outcomes for those that need it most in our community."

According to Ms. Brennan, there is no dedicated taxing district money for healthcare, so her community leveraged county government funding to support FQHC and specialty care expansion. They also used disproportionate share hospital funds to support efforts. The county government donates lease space and seed funding for FQHC expansion projects. In her community, hospitals found value in FQHCs as they are keeping unnecessary or inappropriate visits out of the ER and inpatient setting.

3. Collaboration for outpatient specialty services. Collaborative relationships between hospitals and FQHCs can benefit both provider types through the effective and efficient allocation of resources. FQHCs have provided their communities with patient-centered medical homes, and the collaborations with hospital systems have resulted in the integration of health services. Partnerships have rendered a seamless referral and coordination of services, such as laboratory, radiology, specialty care and telemedicine for patients. This improves access and, in turn, increases patient satisfaction. In addition, patients return to their medical home or are "enrolled" in a medical home if being seen at the partner hospital system.

An example of this type of partnership is the Primary Care Access Network (PCAN) in Orange County, Fla. The group is made up of safety net providers in the area, including representatives from hospital systems, FQHCs (including Community Health Centers in FL), the Florida Department of Health, the county government and other organizations. The community went from having one urgent care center to 10 and one FQHC clinic to 13 FQHC medical home clinics with 92,000 active patients.

"FQHCs are one of a community's greatest assets," said Maureen Kersmarki, director of community benefit and public policy at Adventist Health System, in an interview with the authors of this column. "They provide medical care, education and prevention services to people who may not otherwise have access to care."

PCAN leveraged county government funding to support specialty care expansion and created a specialty program serving patients referred from the PCAN network providers. The specialty care program includes a freestanding specialty clinic that includes co-located hospital systems, a faith-based acute care clinic and hospital/mental health partnership. The program also includes RN medical case management.

In addition, when it is determined that any patient receiving primary medical services at the FQHC requires a specialty referral, the patient receives expedited scheduling services for the specialty clinic, therefore minimizing wait time for treatment.

"Hospitals would be wise to build strong, win-win relationships with FQHCs," said Kersmarki. "Connecting insured, Medicaid and other low-income patients with FQHC medical homes helps everyone. FQHCs not only improve the health of their patients, but help keep preventable health costs down in both hospitals and the community as a whole."

4. Financing population health strategies. Finding revenue streams to implement population health initiatives might sometimes prove difficult, but collaboration will allow hospital systems to expand access to care while containing costs. Organizations may define population health differently, but the partnership's population health strategies and goals should be well-defined and mutually understood by both organizations.

Hospital systems should leverage existing resources and build on safety net resources, like FQHCs, already exiting in their community. In recent years, community transformation grants offered through various foundations and organizations like the Robert Wood Johnson Foundation, U.S. Centers for Disease Control and Prevention and state health departments have become available, and there has been an increase in the development of funding programs aimed at improving care and clinical outcomes while eliminating health disparities.

The Health Resources and Services Administration (HRSA), the federal agency that oversees and manages the CHC program, has emphasized the need for CHCs to improve their financial viability and collaborate with hospitals as was mandated by the Affordable Care Act (ACA).

In the last two years, FQHCs have received HRSA outreach and enrollment funding aimed at enrolling community individuals and families in an ACA marketplace insurance plan. We have also seen many collaborations with payer organizations to include accountable care organizations or health plans establishing childhood obesity prevention programs.

5. Participation in accountable care organizations (ACOs). The ACA enacted a number of programs aimed at transforming the delivery of healthcare to make it more efficient and effective. The promotion of integrated delivery systems through ACOs has the greatest potential to affect FQHCs and encourage hospital systems to include them as a method to improve healthcare quality and restrain healthcare costs.

The rules governing the Medicare Shared Savings Program encourages FQHCs as participants (FQHCs are allowed to form ACOs as well) and proposes a higher shared savings rate for ACOs that include FQHCs, thus providing additional support for why FQHCs should be part of mainstream healthcare delivery. In an article published by the Common Wealth Fund, it cited a national survey that indicated 28% of ACOs had teamed up with community health centers. The article further stated that the integration of FQHCs into ACOs could bring better access to specialists, ambulatory care and hospitals to underserved areas, while increasing the ACOs' expertise in caring for high-need, high-cost patients.

ACOs with FQHC participation will benefit further because of the involvement of organizations with experience managing chronic care populations, reporting quality data and establishing patient-centered medical homes. These are all indications that FQHCs can be valuable partners for hospital systems.

6. Implementing patient navigation strategies. Across the country, hospitals are looking to improve the patient experience and quality of care and reduce the cost of care by methods such as reduction in ER admissions. Hospitals leaders want to manage the health of certain populations in the primary care setting (such as those patients with asthma, diabetes and congestive heart failure), and channel the highest acuity patients to an inpatient care setting. Patient navigation centers have emerged, and partnerships are forming to develop a model of care that facilitates connectivity and communication between organizations. With access to electronic medical records, the development and implementation of health information exchanges (HIEs) is rising.

A robust HIE allows for the exchange of clinical information that better equips healthcare organizations to provide care for patients. For example, nurse case managers at an FQHC can receive data on when their patient was admitted/discharged from the hospital, allowing the case managers to follow up with the patient and make an appointment to see their primary care provider to continue care. FQHCs can manage care for those patient populations with asthma, diabetes or other chronic care conditions and keep the patient out of the ER.

A representative of Chicago's Medical Home Network (MHN), formed in 2010, recently presented at the ACHI Conference on how this group is driving accountable care in their community. MHN was established in response to a report commissioned by the Comer Science and Education Foundation to study the health status of the Medicaid population on Chicago's South Side. MHN created a transformational model of care and launched an innovative connectivity and informational exchange between providers called MHN Safety Net Connect (MHNConnect). This notable IT infrastructure accomplishment allows for care coordination across the continuum of all MHN's providers, which includes Rush University Medical Center, Esperanza Health Centers and Cook County Health and Hospitals System.

According to MHNs website, MHNConnect is a secure, web-based platform that enables virtual integration between provider participants. MHNConnect improves care coordination, tracks patient activity throughout the delivery system, arms participating providers with pertinent patient clinical history and facilitates near real-time information exchange between emergency departments, hospitals and medical home primary care practice sites. Together, these features have helped provider participants effectively monitor the health status and healthcare quality of their patient population.

A representative from Esperanza Health Centers, the FQHC group in the network, also presented at the ACHI Conference and stated that the center has seen its involvement transform the way it delivers care at the practice level. The organization now receives real-time emergency department (ED) visit and hospital admission information, and has assigned care managers to "manage" medium- and high-risk patients. Creating the partnership has allowed the FQHC to become an integral member of the hospital care team, and MHNConnect has yield inspiring results for the network. Hospital readmissions within 30 days of patient discharge decreased from 11.2% to 8.4%, a 25% reduction, and seven-day follow up after ED visits or hospital discharge increased from a 25.3% pre-implementation to an average of 47.2%.

Stronger partnerships, stronger communities
The changing healthcare environment has allowed and encouraged hospitals and FQHCs across the country to collaborate and create models of care that are transforming how healthcare is delivered. As population health continues to be a focus in healthcare and hospitals are taking more leadership roles in their community, it is imperative to foster cross-sector collaborations.

We have discussed six areas of collaboration, but many more innovative collaboration opportunities exist to form partnerships. By collaborating and working in partnership with FQHCs, hospital systems will be better positioned to serve vulnerable populations, connect with their communities and support delivery of comprehensive, patient-centered medical homes established by FQHCS. The time has come to integrate health services and systems and create healthier communities.

Maria Serafine is a consultant with and Joan Dentler is president and CEO of Avanza Healthcare Strategies, which provides hospitals and federally qualified health centers with strategic guidance, with a focus on outpatient services and population health management.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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