Promising Practices: Finance, Operations, HIT

Methodology: This practice enables a health center to develop and implement recognized diabetes prevention (National DPP) and self-management (DSMES) programs to improve patient outcomes, reduce costs, and build capacity by focusing on accreditation/recognition, core components, and a strategic business plan.

To replicate this practice, an organization should focus on adhering to recognition standards and structuring a comprehensive business case for program development and implementation:

1. Identify the Problem and Need (Problem Statement).
◦ Present the prevalence of diabetes nationally, at the state level, and within the health center's patient population.
◦ Discuss the health and financial consequences of diabetes, referencing that the estimated cost of diagnosed diabetes in the U.S. is $412.9 billion, with medical expenditures 2.6 times higher for people with diabetes.
◦ Discuss the gaps in current care for diabetic patients, addressing factors like limited program availability, lack of provider awareness for referrals, limited staffing (diabetes educators), and challenges with insurance coverage and billing.

2. Establish Program Design and Strategy.
◦ Determine eligibility for each program using blood test results (e.g., HbA1C) for risk identification (prediabetes 5.7%–6.4%; diabetes ≥6.5% ).
◦ Identify a strategy for implementing the key components of the National DPP (e.g., managing weight loss of 5–7% and increasing physical activity) and DSMES (e.g., promoting healthy eating, being active, and healthy coping).
◦ Engage key partners, including local pharmacies, health plans, hospitals, and community groups, for effective partnerships.
◦ Incorporate complementary services like Medical Nutrition Therapy (MNT) into the programs, as studies indicate MNT combined with National DPP or DSMES improves outcomes.

3. Adhere to Recognition and Accreditation Standards.
◦ Ensure the program has the capacity to deliver the intervention over at least one year and uses a CDC-approved curriculum for National DPP recognition.
◦ For National DPP, require participants to meet weekly for the first 6 months and biweekly for the last 6 months, and adhere to the CDC requirement that at least 35% of participants are diagnosed via blood testing (or GDM history).
◦ For DSMES, adhere to the six National Standards, including Standards 4 (Delivery and Design) and 6 (Measuring and Demonstrating Outcomes).

4. Develop Implementation and Evaluation Plans.
◦ Determine Key Performance Indicators (KPIs) to measure and evaluate the program's impact, tracking metrics such as: A1C, BMI, LDL-cholesterol levels, and blood pressure (Clinical Outcomes).
◦ Discuss the expected cost savings, showcasing the net monetary benefit (likely to save money) and the Quality-Adjusted Life Years (QALYs) gained.
◦ Establish staffing, roles, and training plans for leadership and staff, and develop a marketing strategy.
◦ Ensure the organization has the necessary infrastructure to quantify intervention costs, measure changes in cost of care, and track patient referrals, data analysis, and billing capability.

Methodology: This practice involves the Board taking a strategic role in evaluating and overseeing the complex, multi-year process of transforming the health center into a Teaching Health Center (THC), ensuring that all necessary financial, human capital, and partnership requirements are strategically managed to address provider shortages and patient access barriers.

To replicate this practice, the Health Center Board should implement the following steps:

1. Use Strategic Planning to Assess Organizational Fit (Tip 1): Dedicate time during the strategic planning process to decide if becoming a Teaching Health Center is the right solution for the health center’s workforce needs.
◦ Review existing data regarding provider burnout, patient access barriers, and workforce shortages.
◦ Review data on provider retention rates and local/statewide workforce numbers, as well as needs assessment data.
◦ Ask the CEO high-level questions regarding staff capacity, workload, and necessary management and oversight.

2. Evaluate Required Human Capital and Financial Investments (Tip 2): Consider the large staffing and financial investments needed for the multi-year process.
◦ Review preliminary numbers regarding staffing needs, time allocations, budgetary impacts, and the cost of the accreditation process and ramp-up period.
◦ Leverage community connections and foundation partnerships to identify specific sources of financial support.

3. Establish Necessary Community Partnerships (Tip 3): Determine if the health center has a plan to build new community partnerships or deepen existing ones to meet the requirement of providing residents with experience in specialty services.
◦ Proactively leverage existing relationships and include board members in reaching out to key community leaders, which can provide leverage in negotiating partnership agreements.

4. Build Board and Staff Infrastructure for Oversight (Tip 4): Determine the necessary staff committees and board structure to support the extensive compliance required for the process.
◦ Decide which standing board committee (e.g., Clinical and Quality Board Committee) will manage the ongoing oversight and compliance of the THC program.
◦ Build board education and updates from the CEO and CMO into monthly board agendas and the annual work plan calendar.

Methodology: This practice enables healthcare providers to effectively implement a team-based PCMH diabetes care management program by standardizing the care management process (Assessment, Plan of Care, Treatment/Monitoring, and Evaluation) and ensuring compliance with NCQA Electronic Medical Record (EMR) documentation requirements.

To replicate this practice, an organization should utilize the care management process, which is circular and ongoing:

1. Screening and Assessment
◦ Screen patients to determine their need and risk level for care management services, gathering key information on past health conditions, utilization of services, polypharmacy, and non-medical health needs.
◦ Complete a comprehensive assessment that identifies the patient’s physical, emotional, socio-economic status, service utilization, and educational needs.
◦ Conduct a diabetes-specific assessment that covers concerns such as the initial diagnosis date, history of diabetes-related ER visits or hospitalizations, blood sugar monitoring frequency, food difficulty, physical activity habits, and medication adherence.

2. Plan of Care Development
◦ Develop the Plan of Care in agreement with the patient and the care manager, ensuring it includes Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) goals.
◦ Establish both self-management goals (focusing on the patient's role) and care management goals (identifying holistic goals).
◦ Ensure the EMR documentation supports NCQA requirements, including incorporating both goal types and providing the patient/caregiver a written copy of the care plan.

3. Treatment, Monitoring, and Care Coordination
◦ Organize and execute continuous care coordination activities by collaborating with the care team and payors.
◦ Identify care gaps (e.g., HbA1c, retinal eye exam) and provide assistance with referrals to specialists, such as Diabetes Self-Management Education and Support (DSMES), Medical Nutrition Therapy (MNT), and podiatry.
◦ Implement referral tracking procedures to ensure referrals are met, including overseeing authorizations, retrieving results/notes, and updating the EMR.
◦ Monitor elements like progress toward established goals, medication use and adherence, appointment compliance, and ER and inpatient utilization.

4. Evaluation and EMR Integration
◦ Review and evaluate the patient’s interventions and goals, clinical outcomes, utilization, and access to care on an ongoing basis.
◦ Utilize the EMR as a foundational element of the PCMH program to create data repositories for performance measurement, organize care around interprofessional teams, and effectively track referrals and labs.
◦ Ensure the EMR allows for timely notification of results and flagging abnormal results for clinicians.
◦ Review the patient's status with the care team and close the case once the care management goals are met.

Methodology: This practice implements a comprehensive, four-phase strategy to ensure health centers are prepared to address the heightened incidence and impact of intimate partner violence, human trafficking, and exploitation that occurs during public health emergencies and natural disasters. This involves adopting standardized interventions like CUES, formalizing community partnerships, and leveraging data systems for proactive patient care.

To replicate this practice, health centers should integrate specific actions across all phases of disaster management:

1. Mitigation (Pre-Crisis Actions):
◦ Formalize Partnerships: Establish formal partnerships with community-based domestic and sexual violence (D/SV) programs, anti-trafficking programs, and legal services.
◦ Standardize Assessment: Integrate healing-centered non-clinical factors of health assessments (like PRAPARE) into routine care to better understand patient needs and risks.
◦ Staff Education: Adopt the CUES Intervention and educate all staff on the dynamics of IPV and lessons learned from past disasters.

2. Preparedness (Pre-Crisis Planning):
◦ Establish MOUs: Establish Memoranda of Understanding (MOUs) with community organizations specializing in IPV and HT to ensure seamless referrals during a crisis.
◦ Invest in Training: Invest in comprehensive staff training focused on empathic listening, healing-centered care, and emergency response protocols.
◦ Adapt Protocols: Adapt identification and response protocols to ensure all patients receive education about available resources during emergencies.

3. Response (Crisis Implementation):
◦ Leverage EHRs: Utilize EHR systems to identify patients with a history of IPV, HT/E to proactively check on their well-being and provide timely support.
◦ Use Assessments: Utilize PRAPARE assessments to quickly identify specific patient needs and guide response efforts.
◦ Maintain Communication: Develop and implement a communication plan that keeps patients informed during an emergency, including specific details on IPV and exploitation resources.

4. Recovery (Post-Crisis Restoration):
◦ Provide Universal Education: Continue providing universal education about legal, social, and safety resources through the evidence-based CUES intervention, collaborating with community partners.
◦ Evaluate and Debrief: Evaluate the response post-emergency and debrief with staff and CBO partners to assess effectiveness and improve future preparedness plans.

Methodology: This practice provides a standardized data strategy that enables health centers and supportive housing partners to reduce the administrative burden associated with developing new tracking mechanisms by leveraging existing data systems (UDS, HEDIS, HMIS) and clinical coding (ICD-10) to monitor the impact of housing on chronic conditions and utilization measures.

To replicate this practice, health centers and housing providers should implement the following steps:
1. Utilize Existing Data Systems for Tracking Outcomes: Focus on tracking outcomes using established data sets already collected by health centers and housing providers.
◦ Health Centers: Analyze existing UDS measures (e.g., chronic conditions, infectious diseases, mental health) and HEDIS measures (e.g., effectiveness of care) at the patient level.
◦ Housing Providers: Leverage data from the Homeless Management Information System (HMIS) regarding housing status, chronic conditions, substance use disorders, and health insurance information.
2. Ensure Point-of-Care Coding for Housing Status: Encourage hospitals and health care providers to use the specific ICD-10 code for homelessness (Z59.0) to allow reports to be generated specifically for patients who have experienced homelessness.
3. Use Screening Tools for Holistic Data Capture: Integrate standardized tools to collect data on social needs and quality of life that may be impacted by housing.
◦ Utilize the PRAPARE tool to screen for patient needs, which provides a holistic view of patients’ health that can be added to the Electronic Health Record system.
4. Analyze Data Based on Housing Milestones: When analyzing health outcomes (e.g., reduction in ER utilization or improvement in chronic conditions), ensure the analysis focuses on the pre- and post-housing move-in date rather than the project start or enrollment date.
5. Include Qualitative Data for Storytelling: Supplement quantitative data with anecdotal evidence regarding people’s experiences—such as increased engagement in care, better medication management, or reported feeling better—to tell the story of success that may not yet be quantifiable.

Methodology: This practice enables health centers to maintain continuity of care and effectively prepare for, respond to, and recover from natural or manmade emergencies that affect healthcare delivery or its infrastructure. It standardizes and formalizes emergency management support by using a collaborative coalition structure (like the PCA Emergency Management Advisory Coalition, EMAC).

To replicate this practice, an organization or network must establish a coalition based on continuous coordination and technical assistance (T/TA):

1. Formalize the Coalition Structure and Mission.
◦ Establish a formal coalition (like EMAC), which grew out of a prior HRSA Learning Team.
◦ Define the coalition's mission and purpose to coordinate and provide support to health centers during emergencies.
◦ Develop a governing structure, such as implementing a two-year cycle for Chair/Co-Chair roles and establishing a Steering Committee.

2. Provide Continuous Training and Technical Assistance (T/TA).
◦ Convene regular meetings, such as monthly virtual and annual in-person gatherings, for members.
◦ Provide opportunities for T/TA, which includes supporting the onboarding of new emergency management staff at health centers, Primary Care Associations (PCAs), Health Center Control Networks (HCCNs), and National Training and Technical Assistance Partners (NTTAPs).
◦ Ensure training aligns with HRSA’s goals for PCAs, such as increasing the percentage of health centers that receive T/TA on leveraging CMS requirements to effectively align with federal, state, tribal, regional, and local emergency preparedness systems.

3. Develop and Leverage Resources and Partnerships.
◦ Partner at the local, state, national, and federal levels, as well as with relief organizations.
◦ Leverage resources and act as subject matter experts on emergency management for health centers.
◦ Develop and share emergency management resources, including trainings, templates, and checklists, and utilize an online resource repository.
◦ Implement systems to ensure timely and accurate PCA reporting on health center operational status during disasters and/or public health emergencies, as mandated by HRSA.

Methodology: This practice enables a health center to evaluate its current state of health information technology interoperability across key organizational and technical domains (Technology and Data, Privacy and Security, Strategy and Governance, and Program Design) using a structured, self-assessment methodology to create a cohesive organizational data strategy and prioritize next steps for quality improvement.

To replicate this practice, health centers should implement the following steps:

1. Form the Assessment Team and Review the Tool: Assemble a multi-disciplinary team, such as an existing data governance or improvement team, to discuss and complete the score card. Review the scorecard as a whole and address any questions about terminology or internal background knowledge.

2. Conduct the Structured Self-Assessment: Systematically grade the health center's readiness across all key areas of interoperability on a scale of 1 through 5, where 1 is poorly developed and 5 is well developed.
◦ Assess Process, which refers to structured processes, policies, and procedures within the health center.
◦ Assess Infrastructure, which refers to structural capacity and ability within the health center’s technology and staffing structure.
◦ Assess Action, which refers to full implementation to the point of active and ongoing use and engagement.

3. Analyze Results and Prioritize Gaps: Use the score card results to inform next steps, addressing areas where the score indicates poor development.
◦ Prioritize improving Data Ingestion and Data Sharing capabilities using standardized formats such as HL7® V2 messages, FHIR®, and protocols like Direct Messaging.
◦ Prioritize putting appropriate safeguards in place where gaps were identified in the Security Risk Assessment (SRA).

4. Align Strategy and Ensure Governance: Use the assessment to align metrics and improvement efforts to create a cohesive organizational data strategy.
◦ Establish necessary Data Governance policies and committees, comprised of personnel from different departments, to ensure shared definitions, compliance, and specific responsibilities are assigned to data stewards.
◦ Establish organizational Interoperability Goals, which may include streamlining care by reducing duplication, improving population health management, and furthering patient safety.

5. Monitor and Re-evaluate Progress: Use the score card to guide discussions and monitor progress over time, tracking performance across key performance indicators (KPIs). Re-evaluate the scorecard once next steps have been completed.

Methodology: This practice implements a bi-directional medical and dental integration model, initially piloted at a single, co-located site, to ensure diabetic patients receive both medical and oral health services, which supports improved chronic disease outcomes. The methodology leverages training, streamlined workflows, and shared data.

To replicate this practice, health centers should implement the following steps:

1. Establish a Small, Co-located Pilot Team: Start the initiative as a pilot project at a single clinic site where medical and dental services are co-located, and use quality improvement methodologies like small-scale tests to implement new workflows.

2. Implement Bi-Directional Training: Ensure cross-training occurs between departments:
◦ Train the medical team (PCPs, MAs, Nurses) on how to conduct a limited oral health evaluation and how to schedule dental appointments.
◦ Train the dental team on A1c lab testing protocols, including where to find A1c results and how to order an overdue A1c lab using the EHR (EPIC).

3. Integrate Oral Health Risk Assessment into Medical Visits: During the medical visit, provide education on the diabetes/oral health relationship and conduct a short oral health risk assessment.
◦ Utilize a streamlined, short risk assessment tool (e.g., three questions) to minimize the time burden on the medical team, capturing results using EHR forms (e.g., Smart Phrases in EPIC).

4. Ensure Direct Dental Scheduling: Optimize the referral process by having the medical assistant make a follow-up dental appointment directly into the dental schedule before the patient leaves the medical exam room.

5. Utilize Dental Visits for Diabetes Tracking: During subsequent dental appointments, the dental team should check the date of the patient’s last A1c test and, if needed, ensure the patient stays up-to-date by ordering an overdue A1c lab.

Methodology: This practice enables health centers to integrate HIV/HCV prevention and testing into MOUD care settings, building patient trust and providing essential wraparound services to reduce infection risk and support patient stability.

To replicate this practice, an organization should implement the following steps:

1. Standardize Routine Testing and Documentation.
◦ Integrate routine HIV and HCV testing into the MOUD intake process.
◦ Embed reminders into Electronic Health Records (EHRs) to support consistent testing and timely follow-up.

2. Ensure Staff Training and Patient-Centered Approach.
◦ Train all staff annually in Motivational Interviewing (MI) principles to ensure consistent use of this standard of care.
◦ Utilize a respectful, patient-centered approach that focuses on building trust and stability.
◦ Employ peer support to help patients navigate care with empathy.

3. Establish Comprehensive Care and Referral Pathways.
◦ Establish strong referral pathways for mental health and behavioral health support.
◦ Utilize community organizations to establish strong partnerships for wraparound services (e.g., housing, employment, food assistance).
◦ Collaborate with community partners to provide safer use supplies.

4. Define Partnership Workflows.
◦ Establish clear workflows and shared goals with partners to support patient connection to services and reduce care gaps.
◦ Facilitate warm hand-offs to community partners to maintain patient engagement.

Methodology: This practice utilizes a detailed Memorandum of Understanding (MOU) template to formalize roles, responsibilities, and resource sharing between a Health Center and a Domestic Violence/Sexual Assault/Human Trafficking (DV/SA/HT) CBO to strengthen collaboration, promote patient safety, and ensure bidirectional warm referrals for patients and staff.

To replicate this practice, organizations should implement the following steps:

1. Formalize the Partnership and Define Purpose: Establish the agreement by having designated agents from both the Health Center (HC) and the DV/SA/HT/CBO agency sign the MOU.
◦ Define the core purpose of the collaboration, such as strengthening staff collaboration, promoting health and safety outcomes, and coordinating services including health enrollment and transportation.

2. Define Mutual Roles and Responsibilities: Clearly outline the specific duties and roles for each entity within the MOU structure.
◦ HC Responsibilities: Include serving as a primary healthcare referral for clients, training DV/SA/HT/CBO advocates on health center enrollment and services, and drafting and reviewing IPV/HT policies and procedures.
◦ DV/SA/HT/CBO Responsibilities: Include training health center providers and staff on DV/HT dynamics and community supports, serving as a primary referral for HC patients or staff in need, and offering advocacy support (onsite or virtual via telehealth).

3. Commit Resources and Structure Meetings: Ensure the partnership is supported by dedicated resources and consistent communication.
◦ List specific resources (e.g., additional staff time, mobile health services, office space for co-located advocates, 24/7 hotline support) that each entity will provide to support the project’s efforts.
◦ Schedule initial and recurring meetings between representatives of both agencies to understand services, discuss needs, and maintain the recurring schedule.

4. Establish Tracking and Evaluation Mechanisms: Agree on tools to measure the success and challenges of the collaboration and outcomes.
◦ Agree to review and discuss evaluation tools, such as a referral tracking tool and a Quality Assessment/Quality Improvement tool used every six months.
◦ Include plans for collecting data via client/patient satisfaction surveys and provider/staff training evaluations.

Methodology: This practice provides a structured, replicable tool for FQHCs to review complex payer contracts, particularly those involving Value-Based Payment (VBP), ensuring critical operational and financial terms are defined and negotiated before execution.

To replicate this practice, health centers should utilize the contract review checklist to systematically assess general, VBP, and shared savings terms for every payer contract received:
1. Confirm General Contract Feasibility and Scope: Before accepting a contract, ensure clarity on foundational operational details.
◦ Verify that the contract clearly specifies the fee schedule (e.g., PPS/APM rates) and defines the exact scope of services covered.
◦ Review and understand the terms and conditions for contract termination by either party.

2. Analyze Value-Based Payment (VBP) Components: If VBP is involved, confirm all requirements and metrics are understood.
◦ Determine the methodology for patient assignment (e.g., prospective attribution or retrospective reconciliation).
◦ Define the total risk/total gain potential for the FQHC under the agreement.
◦ Identify the source and frequency of data sharing, confirming the evaluation methodology (e.g., health plan claims data vs. FQHC quality data).

3. Detail Shared Savings/Losses and Benchmarks: If the model includes financial risk or reward, confirm all benchmarks are established.
◦ If applicable, clearly articulate the shared savings/loss percentage and specify how savings are calculated.
◦ Ensure the benchmark and baseline for target costs are explicitly defined and understood by both parties.
◦ Verify that Stop-Loss protection is included to limit the FQHC’s financial risk exposure.