Enhancing the Capacity of Community Health Centers to Achieve High Performance: Findings from the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers

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Federally Qualified Health Centers (FQHCs) are community-based health centers that provide comprehensive primary health care and behavioral and mental health services to all patients regardless of their ability to pay or their health insurance status. Located in medically underserved areas, FQHCs are a critical component of the health care safety net. FQHCs serve patient populations that are predominantly low-income, minority, and uninsured or rely heavily on public insurance. Over 1,000 health centers operate approximately 6,000 sites throughout the United States and territories. In 2010, these centers will serve an estimated 20 million patients. The demand for health services provided by federally qualified health centers is likely to increase over time, particularly with the passage of the 2010 Patient Protection and Affordable Care Act, the nation's health care reform legislation. Since health centers play such a critical role in providing quality care to vulnerable populations, it is important to assess system capacity and spotlight areas where support for improvements can lead to increased access and quality of care.

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In 2009, The Commonwealth Fund conducted a national survey of all federally qualified health centers in order to assess whether FQHCs have the capacity to function as high-performing sites of care. A total of 795 centers responded to questions about their patients' access to care, including after-hours or 24/7 care, as well as questions about obtaining specialist referrals and procedures; coordination of care among providers and across settings; and engagement in quality-improvement activities and performance reporting. The survey also assessed health information technology adoption, the ability to track patient information and manage patient care, and the identified opportunities to strengthen health center capacity to be patient-centered medical homes (PCMHs).

Survey findings indicate that many health centers can provide timely access to on-site care. Many centers face barriers, however, providing off-site specialty care services for their patients, even if these patients have insurance (Exhibit ES-1). Centers that are affiliated with hospitals, however, can more easily obtain off-site imaging or follow-up treatment for their patients. Affiliated centers also reported more timely communication with hospitals about the care their patients receive in the ER and hospital, such as being notified that their patients have been admitted and receiving a discharge summary from hospitals.

  • Nearly all (91%) health centers reported it is somewhat or very difficult to get off-site specialist care for their uninsured patients; 71 percent and 49 percent of centers, respectively, reported it is difficult to get specialist care for their Medicaid fee-for-service patients and Medicare patients.
  • Six of 10 centers without any hospital affiliation for referrals reported difficulty in obtaining off-site specialty care for their Medicare patients, compared with 46 percent that have hospital affiliations.
  • Obtaining off-site specialty care for their uninsured patients remains difficult regardless of whether centers have referral affiliations.

The survey also finds that 40 percent of centers have electronic medical records (EMRs). Yet, the capacity for more advanced health information technology (HIT), such as electronically ordering prescriptions and tests, creating and maintaining patient registries, tracking patients and tests, and providing alerts or prompts remains highly variable among centers. Findings indicate that centers that have more advanced HIT systems are better able to track patient test results, generate information about their patients, and remind clinicians to provide patients with tests results or appropriate services at point of care (Exhibit ES-2). More advanced use of IT systems enables centers to better manage care coordination among providers and across settings of care, such as hospitals and ERs.

  • Twice as many health centers with advanced HIT use indicate their providers receive alerts to provide patients with test results than do centers with the lowest IT functional capacity (51% vs. 25%).
  • Forty-three percent of centers with advanced HIT use report that their providers will receive a prompt at point of care for appropriate services needed by patients; by comparison, just 10 percent of centers with low HIT use are able to do this.
  • Fifty-five percent of centers with advanced HIT use can track referrals until a specialist consultation report returns to the referring provider; only 42 percent of centers with low IT use have this capacity.

The survey also assesses FQHCs' capacity to serve as patient-centered medical homes. These have been identified as models for delivering high-quality care and for reducing costs. Using the National Committee for Quality Assurance's medical home measures as a guide, we created a scale to describe the stage of development of health centers as a "patient-centered medical home." The findings indicate that although many federally qualified health centers possess capacity in a number of the PCMH domains, few report capacity in all five. Improved access, communication, and coordination between specialty care providers and local hospitals are characteristics of health centers with increased capacity to function as patient-centered medical homes. These findings point to the advantages of having the infrastructure and systems that are the hallmarks of medical homes in place when endeavoring to improve coordination of care beyond a health center's walls.

  • More than twice as many centers with all the attributes of a medical home are notified when their patients go to the ER, compared to centers with only a few PCMH attributes (45% vs. 20%).
  • A greater number of centers that have capacity in all five medical home domains receive a discharge summary from hospitals compared with centers that have just three to four domains or zero to two domains (45% vs. 34% vs. 21%, respectively).

Policy Recommendations

The health care reform bill passed recently by Congress calls for an increase in FQHC funding of $11 billion over five years to support both services and expansions. Furthermore, community health centers should expect additional resources routed through various grant programs supporting workforce development and implementation of health information technology. The survey results show that this increased investment must be coupled with payment incentives and infrastructure support to ensure that existing and new centers continue to fulfill and strengthen their community-based mission as high-quality, comprehensive, patient-centered sites of primary care for our nation's most vulnerable populations.

Specifically, the survey results point to a number of ways in which federal and state leaders can help strengthen the nation's community health centers and achieve high performance. These priorities include: 1) developing a policy to support and facilitate health centers, specialty care providers, and public hospitals to formalize referral and coordination partnerships so that they can ensure mutual accountability for vulnerable patients; 2) encouraging health centers to improve office systems and processes that will enable them to function as patient-centered medical homes; 3) reforming payment to health centers in a way that will promote and sustain patient-centered medical homes; and, 4) forwarding adoption and use of health information technology (HIT), which will give health centers the ability to identify, track, and manage patients' health needs.

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