Innovative Community-Based Approaches to Program and Policy Development Aimed at Reducing Disparities in Primary Care Sam S. Shekar, M.D., M.P.H. Associate Administrator for Primary Health Care and Assistant U.S. Surgeon General American Public Health Association (APHA) 131 st Annual Meeting and Exposition November , 2003

Health centers that receive a federal grant are called Federally Qualified Health Centers (FQHCs) HRSA provides federal grant funding to health centers to deliver primary and preventive care Authorized under 2002 Amendments of the Health Centers Consolidated Care Act of 1996, section 330 of the Public Health Service Act Consolidated health centers include: – Community Health Centers – Migrant Health Centers – Health Care for the Homeless Programs – Public Housing Primary Care Programs – School-Based Health Centers FQHCs and Health Centers

$6M annual budget 50,000 encounters/year 14,000 patients/year Services: – General primary care – Preventive screenings – Chronic disease management – Enabling services Source: BPHC, 2002 Uniform Data System (UDS) Typical Health Center 30 clinicians/clinical professionals 10 enabling staff 40 administrative staff

 11.3 Million served  44.7 Million patient encounters  >3,400 service sites  88.1% below 200% poverty  38.9% uninsured  63.9% racial/ethnic minority  Serve all ages – 12.8 % 4 and under – years – years – years – and over Presidential Initiative Calendar Year (CY) 2002 Source: Uniform Data System, CY 02, June 2003

Health Centers: Sources of Funding ( FY 2002 est) Source: BPHC, 2002 UDS

Health Centers and Medicaid Relationship: -- 1/3 of Health Center Patients -- 1/3 of Health Center Total Revenue -- 2/3 of Health Center Patient Revenue Result: Decreased Avoidable Hospitalizations – Health Center Medicaid patients are 22% less likely to be hospitalized for potentially avoidable conditions than those obtaining care elsewhere. Falik et al. Medical Care Vol. 39, No 6; Health Center Medicaid patients are 11% less likely to be hospitalized for potentially avoidable conditions than those with a usual source of care who obtained care elsewhere. Ambulatory Care Sensitive Conditions (ACSC) II Study to be published. Lower Health Care Costs – Cost of treating Health Center Medicaid patients is 30-34% less than cost for those receiving care elsewhere; 26-40% lower for Rx; 35% lower for diabetics; 20% lower for asthmatics. Center for Health Policy Studies. Final Report; November 1994.

President’s Initiative to Expand Health Centers By 2006: 1,200 new or expanded health centers 6 million additional people

Access to Care: Uninsured Health Center Patients Face Fewer Primary Care Access Barriers than Uninsured Overall Source: Carlson et al. Primary Care of Patients without Insurance by Community Health Centers (CHCs). Journal of Ambulatory Care Management (JACM) *p<.001

A national effort to improve health outcomes for all medically underserved people HRSA Health Disparities Collaboratives Care Management Collaboratives – Diabetes, Cancer, Cardiovascular, – Asthma, Depression, HIV/AIDS Prevention Collaboratives – Diabetes – Healthy weight, tobacco use, blood pressure, cholesterol, immunizations, lead screening, oral health Finance Redesign Pilot Perinatal Risk Management – Planned

HRSA Health Disparities Collaboratives Patient self-management Evidence based decision support Clinical information system to monitor clinical outcomes Delivery system designed for patient and family goals Organization of health care for quality Community partnerships The Care Model includes six essential elements for improving the care of people with chronic illness:

Health Center Patients With Diabetes Are Twice As Likely To Have Their Glycohemoglobin Tested on Schedule % 20% Health Center Patients National Norm Source: MDS Associates, Evaluation of the effectiveness and Impact of Community Health Centers, based on the National Health Interview Survey, 1999

Collaborative Success “With federally funded health centers having fully embraced the (Health Disparities Collaborative) model…this has become arguably the largest, most important health care quality improvement initiative in the country. It’s exactly what the health care system needs right now - a demonstration that it is possible both to improve care dramatically and even reduce health care costs.” Tracy Orleans, Ph.D., senior scientist at the Robert Wood Johnson Foundation Advances Online, Robert Wood Johnson Foundation Newsletter, October 2002

HCAP Partnerships Healthy Communities Access Program (HCAP) Newly Established Legislative Authorization (340 Public Health Service (PHS) Act New Direction – Stronger Emphasis on Health Care for Underserved – Strengthens Vertical Integration – Improves Chronic Care Coordination – Builds Information Technology Systems – Assists Infrastructure Development Healthy Community Access Program – FY new HCAP communities in 20 states received awards in FY HCAP communities received continuing funds. Currently, HRSA has a total of 164 HCAP grantees in 43 states

Public Health Center Entities Under section 330(l)(2)(A), the Secretary may allocate up to 5% of its section 330 dollars to public centers or entities that do not independently meet governing board requirements. In 2002, 39 public entities currently received $41 million of community and migrant health center funds. Public Health Entity Examples Multnomah County Public Health Department – Portland, Oregon Will County Community Health Center – Joliet, Illinois City of Austin Primary Care Department – Austin, Texas Lexington-Fayette County Health Dept. – Lexington, Kentucky Denver Health and Hospitals – Denver, Colorado Palm Beach County Health Dept. – West Palm Beach, Florida