Profile of a Region X Health Center
Monday, December 14, 2015
Lynn Gerlach, Development and Communication Manager
Every year we gather data from our member health centers and use the information to plan our support, training and technical assistance on their behalf. HRSA tells us we must do this, but we’d do it anyway. After all, our mission is to serve the community health centers of Alaska, Idaho, Oregon and Washington. We’ve concluded our annual member survey, and this year we added something new (that we promise NOT to do annually): a member census. We want to collect both quantitative and qualitative data from our health centers. We’re pretty excited about what we now know about our members, and we’d like to share it with you.
A caveat first, of course: Not every health center responds when we conduct surveys. And not all respondents are in the same job role. Some people acknowledge that they’re only “pretty sure” of a few answers; others probably have an exact, informed response. So, is our data perfect? Certainly not. But we think it gives us a pretty good assessment of the status and concerns of the Northwest health centers and might even provide a suggestion of what a “typical Region X health center” might look like if such a thing as an “average health center” existed.
Let’s start with the fairly incontrovertible facts:
· Sites: The vast majority of Region X health centers have fewer than 15 sites; most have three to seven sites.
· FTEs: As might be expected, then, most of them have fewer than 200 full-time employees.
· Outliers: One member, however, has 90 sites and more than 2000 employees! Another one has a single site and 1.5 FTEs. (So much for “average,” right?)
· Special Populations: Nearly half (about 42%) receive funding to serve HRSA’s “special populations”: migrant/seasonal farmworkers, individuals experiencing homelessness, residents of public housing.
· EHR: 100% of responding health centers have an operational electronic health record! Most of them were launched between 2007 and 2011, and 11% of respondents noted that they have already launched additional components or switched to an entirely new system.
· EHR Specifics: 35% indicated they are NextGen users; 22% use Epic; 10% use Centricity; 8% use eClinicalWorks; about ten other specific brands were mentioned.
· HCCN: Only 28% of respondents indicated they belong to a Health Center Controlled Network.
· PCMH recognition: 78% indicated they have recognition, most by NCQA, and more than 60% are recognized at Level Three.
· Enabling Services: All said they offer eligibility assistance, and nearly all identified interpretation, case management and health education as enabling services they offer. More than 80% offer services they would consider “outreach,” and 66% said they offer transportation services.
· Pain Management/Opioid Safety: Only 35% of respondents indicated they have a buprenorphine waivered provider on staff.
· Students: 81% offer student rotations in their clinics!
· Recruitment: 35% employ their own physician recruiter, and half of them contract with a staffing agency.
· Memberships: All census respondents indicated their health centers are NWRPCA members, and all but one is a member of the home-state PCA. 63% indicated they also belong to the national association (NACHC).
We wondered how respondents of our census perceived their health centers’ success in fully integrating services, since so many consider themselves patient-centered medical homes or patient-centered primary health homes. Acknowledging that these responses were best guesstimates of the person completing the census, and they were not given any definition of “integrated,” we collected the following perspectives:
· Behavioral Health Integration: 37% felt their CHC was more than halfway there, while 25% believed their CHC was more than ¾ fully integrated.
· Dental health Integration: 33% indicated the job is more than half finished, with 16% putting their health center’s level of integration at higher than 75% of the goal.
· Vision Health Integration: 67% admitted their health center hadn’t started, while 18% felt they were ¼ of the way there. Four respondents indicated their CHC was close to goal.
Each year we focus our annual member survey a little differently, based on staff’s requests for information. Our survey focus this year was on workforce development, a perennial problem for our CHCs. Given 15 clinical job roles, respondents identified seven of them as “critical for recruitment.” The one most often cited as critical was “family medicine MD/DO” followed by “NP/nurse.” A close third choice was “family medicine MD/DO with OB.”
Given 15 administrative job roles, respondents cited four as “critical for recruitment,” with biller/coder most often selected, followed by IT professional. Case manager and patient care coordinator were also selected by more than one-third of respondents as critical for recruitment. Asked how they seek to fill open positions, the vast majority selected “advertise on our own web site” and “use online job boards.” Well over half also use a recruiter or a recruitment firm and/or attend job fairs.
52% of respondents acknowledged having used the NWRPCA Career Center in the past year. Of these, 73% rated it as easy to use. Half were “somewhat satisfied” in its ability to help fill vacancies, and 26% rated the Career Center as “very valuable” for recruitment.
So, what can we, the regional primary care association, do to help?
· If we were to hold a job fair in conjunction with one of our conferences, 27% would be highly interested in participating.
· If we offered a referral service for fee-upon-hire, 37% would be highly interested in using it.
How would the health centers like to proceed in solving their recruitment and retention problems? Well over ¾ already host students for clinical rotations, and nearly half identified such rotations as something they wish to continue in the future. 20% are strongly interested in developing residency programs, and 17% indicated strong interest in partnering with hospitals.
Our Other Programs
Known for our Education and Training services, particularly our conferences, we like to know what hot topics for training are on the minds of our health center leadership. Not surprisingly, respondents listed “staff recruitment and retention” and “provider retention” as the top two areas in which they hope we will provide training in the upcoming years. The movement from volume-based to value-based reimbursement was also cited as of primary training importance.
What keeps them from attending our trainings, we wondered? The answers, overwhelmingly, were cost and lack of staff availability to invest the time. Nearly 70% cited “email” as the way they are most likely to hear about our conferences and trainings.
Our Community Health Improvement program requested some data on our centers’ response to the social determinants of health (SDOH). Over half of respondents indicated their health centers formally screen for social determinants of health. The SDOH issues cited as their patients’ greatest unmet needs were finances/income/costs and housing. The next two most frequently cited were employment and education. Once patients are enrolled in insurance coverage, respondents reported, the next likely priority will be patient activation followed by patient navigation and then patient retention.
Member Services, perennially interested in our Chronic Pain Management/Opioid Safety Initiative, wondered which tools members would most like us to provide. With assistance from the University of Washington COPE program, we offered a list and, as is generally the case, respondents identified all choices as highly important to them. Highest-rated were information on alternatives to prescription opioids for chronic pain and a tool to deal with difficult patient situations.
So, what’s “average”?
Given all that information, how would you “profile” the typical Region X health center, if it were even possible to do so? We’ll take a stab at it, and then we welcome your retorts, revisions and reminders. Note that we will now fill in with additional information we collected in our census and survey that we have not specifically mentioned above.
Typically, the Northwest health center has five sites and employs about 175 full-time staff, including ten clinicians (physicians, mid-levels and behaviorists – possibly a dentist). The CHC uses an electronic health record to coordinate care and activate patients; it’s likely that EHR will be NextGen or Epic. A typical Northwest health center has some level of PCMH recognition now, most likely from NCQA, but, if in Oregon, more likely from the Oregon State Health Authority. The center has probably done extensive work on integrating behavioral health, has made inroads into dental health integration, and will deal with vision care integration in the future.
Recruiting and retaining highly-skilled, mission driven staff is the perennial problem, with family medicine doctors the most hard to find. The CHC’s leadership is constantly looking for better ways (“best practices”) to recruit staff that will stay despite its [and these items are taken verbatim from our survey] remote location, high cost of living, a staffing structure that is perceived as “inadequate,” and other perceptions that form barriers to retention, including: “poor work/life balance… inadequate compensation or bonus structure… and lack of upward mobility.” Good billers and coders are also in short supply, along with IT professionals, case managers and patient care coordinators. And front desk staff are easily lured away once the CHC has trained them up and offered them some excellent OJT.
The typical health center always has open positions advertised on its web site, and it’s likely to also post them on the NWRPCA online Career Center. CHC staff are in regular contact with recruiting firms and make the rounds of job fairs. They welcome students in for whatever rotations they feel they can precept with quality, hoping to “grow their own” docs for the future. The C-suite engages in regular discussion about possibly partnering with a neighboring hospital or starting its own residency, but a constantly changing healthcare landscape makes major decisions like that fraught with economic uncertainty. What might be a very good move, financially, could turn out to be a disaster in the future. Who knows? And when will pay for performance supersede fee for service? Who knows? Most of these leaders have been at this particular health center for more than five years, and no two years have been alike!
Leaders have a pretty good idea what training they’d love to provide for their staff members – to make them better at their jobs, give them job satisfaction, and keep them. However, even if the budget allows them to send staff to trainings, the work schedule often does not. They do encourage their staff to take advantage of affordable online learning scheduled during the work day.
The health center’s patient population has grown astronomically in the past two years, thanks to all that effective outreach (and inreach) and enrollment in the health insurance marketplace. Many of the new patients, never before insured, are eager to take advantage of their new benefits, and many bring with them medical complexities developed over years of inadequate primary care. Frontline staff understand that finances are still the biggest factor that will keep these new patients away: Their income might be too low to divert dollars for copays and premiums, or the cost of the care they really need is beyond their plan’s benefits. Many new patients have unreliable housing situations, and many suffer food scarcity. Even more have an unreliable employment situation and/or lack the education they need to hold a job securely.
The health center is more likely than not to screen for such social determinants of health and then provide whatever enabling services it can. Interpretation for speakers of at least five languages is a likely service. A typical health center will probably have a handful of staff that perform invaluable outreach services. These are individuals without a professional certification who speak the community’s language and know its culture and, perhaps most important, are trusted by the community. This health center might or might not call them Community Health Workers.
Our typical health center contracts with a local addiction center, where some patients are referred, but also has on staff a part-time behavioral health expert to take a warm handoff and serve other patients. Region X health centers regularly view the safe treatment of chronic pain as an ongoing challenge, and this “typical” health center might be struggling with patients on dangerously high levels of opioids.
Providers are expected to be “productive,” and their productivity is generally measured in terms of number of patients seen in a typical day. Some of those providers have also learned to adapt to the rather foreign concept of typing at a computer while in the exam room with a patient, and all of the providers have recently made the daunting shift to a new medical coding system called ICD-10. Their notes in the electronic record generally demand another few hours of “charting” after the last patient of the day has been seen.
Correct medical coding is the lifeblood of the CHC’s revenue stream, as they rely on reimbursement from Medicaid, Medicare and private health insurance plans to keep their doors open. Days’ cash on hand is always a worry and, although leaders give lip service to the mantra, “no margin, no mission,” the margin is hard to maintain. The Executive Director of this typical health center is, more likely than not, a baby boomer of retirement age. Soon a succession plan will need to be implemented, with the fear that loss of leadership will also mean loss of valuable institutional knowledge. The health center looks to its state and regional primary care associations for the training and technical assistance needed to address the ceaseless onslaught of new challenges. That said, the staff members who stay have absolutely no doubt that the work they do truly provides a safety net for the local community.