Bureau of Primary Health Care Update for the North Carolina Community Health Center Association Darryl Burnett Public Health Analyst Central Southeast Division U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care June 20, 2013

Primary Health Care Mission Improve the health of the Nation’s underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services 2

Health Center Program Overview Calendar Year 2011  1,128 Grantees  8,500+ Service Sites  80 Million Patients Visits  Over 138,000 Staff  9,937 Physicians  6,934 NPs, PA, & CNMs  Over 200 Look-alikes that serve nearly 2 million patients Source: Uniform Data System, 2011, Service Sites: HRSA Electronic Handbooks 20.2 Million Patients  93% Below 200% Poverty  36% Uninsured  62% Racial/Ethnic Minorities  1,087,000 Homeless Individuals  863,000 Farmworkers  188,000 Residents of Public Housing 3

Health Center Program Growth: National Impact Growth from (% Increase) Patients17,122,53518,753,85819,469,46720,224,7573,102,222 (18.1%) Sites7,5187,8928,1568, (13.1%) Jobs113,059123,012131,660138,40325,344 (22.4%) Source: Uniform Data System, and HRSA Electronic Handbooks 5

Health Center Performance Calendar Year 2011 Among Health Center Patients: 70% entered prenatal care in the first trimester Rate of low birthweight babies (7.4%) continues to be lower than national estimates (8.1%) 44% of children received all recommended immunizations by 2 nd birthday 63% Hypertensive Patients with Blood Pressure <= 140/90 71% Diabetic Patients with HbA1c <= 9 $654 Total Cost per Patient $144 per Medical Visit For more information: Source: Uniform Data System, National Birthweight Data: Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for National vital statistics reports web release; vol 60 no 2. Hyattsville, MD: National Center for Health Statistics

North Carolina Health Centers Calendar Year 2011 North Carolina Health Center Grantees In 2011, 28 Health Centers Served 411,015 patients: 52.1% were uninsured 95.1% were at or below 200% of poverty 56.1% Female 58.7% nationally 22.5% Children < age 18 32% nationally 8.7% Seniors age % nationally Served by (FTEs): – Physicians – Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives 7 Source: Uniform Data System, 2011

North Carolina Health Centers Calendar Year Fiscal Year 2012 PERFORMANCE Among North Carolina Health Center Patients: 76.4% entered prenatal care in the 1 st trimester Rate of low birth weight 7.7% 45.2% of children have received all recommended immunizations by second birthday 76.7% Diabetic Patients with HbA1c <= % Hypertensive Patients with Blood Pressure <= 140/90 $511 Cost per Patient; $154 per Visit FUNDING $31.0 M base operational grants (FY ‘12) $18.2 M New ACA grants $10.3M – Capital Development - Building Capacity $500 K – Capital Development - Immediate Facility Improvement Grant $1 M – School Base Health Center Capital Grant $935 K – Patient Center Medical Home $114 K – HIV 8 Source: Uniform Data System, 2011 and HRSA Electronic Handbooks

Bureau of Primary Health Care (BPHC) Organizational Structure 9

Central Southeast Division Regions: 4 and 7 Five Branches: –East Atlantic Branch: North Carolina and South Carolina –Gulf Coast Branch: Alabama and Florida –Mid-South Branch: Kentucky and Tennessee –Midwest Branch: Iowa, Kansas, Missouri, and Nebraska –Southeast Branch: Georgia and Mississippi 10

Primary Health Care Our Focus 11

12 Primary Health Care Priority Areas Identified in 2012 Grantee Satisfaction Study Technical Assistance and Support (72/1.0) BPHC Tech. Assist. – Website (70/0.7) FTCA Program Information (73/0.8) BPHC Program Policy Communications (73/0.6) BPHC Electronic Submission Process (62/0.5) Policy Information Notices Tech. Assist. (72/0.5) Grantee-Project Officer Relationship (78/1.7) Application Process (71/0.4) UDS Technical Assistance (71/0.3) UDS Program Report (71/0.3) Application Process Tech. Assist. – Primary (71/0.2) BPHC Tech. Assist. – Helpline (72/0.1) Application Process Tech. Assist. – Secondary (75/0.1) More Immediate Priority Less Immediate Priority

Impact-BPHC Quality Strategy 1.Implementation of QI/QA Systems All Health Centers fully implement their QI/QA plans 2.Adoption and Meaningful Use of EHRs All Health Centers implement EHRs across all sites & providers 3.Patient-Centered Medical Home Recognition All Health Centers receive PCMH recognition 4.Improving Clinical Outcomes All Health Centers meet/exceed HP2020 goals on at least one UDS clinical measure 5.Workforce/Team-Based Care All Health Centers are employers/providers of choice and support team-based care Priorities & Goals ACCESS COMPREHENSIVE SERVICES INTEGRATED SERVICES INTEGRATED HEALTH SYSTEM Better Care ⃘ Healthy People & Communities ⃘ Affordable Care 1.Programs/Policies 2.Funding 3.Technical Assistance 4.Data/Information 5.Partnerships/Collaboration Strategy Implementation 13

Current Program Impact: Key North Carolina Indicators % of Health Centers with EHR Implementation (UDS 2011)  78.6% have EHRs at all sites used by all providers  3.6% have EHRs at some sites used by some providers % of Health Centers Achieving Patient-Centered Medical Home Recognition (as of February 1, 2013)  46% of North Carolina State health centers are participating in Patient-Centered Medical Health Home Initiatives (PCMHHI)  10.7% have achieved Patient-Centered Medical Home (PCMH) recognition % of Health Centers Meeting/Exceeding Healthy People 2020 Goals (2011):  50.0% Meet/Exceed Hypertension Control Goal of 61%  17.9% Meet/Exceed Diabetes Control (HbA1c ≤9) Goal of 85%  17.9% Meet/Exceed Early Entry into Prenatal Care Goal of 78%  14.3% Meet/Exceed Low Birthweight Goal of 7.8% Starting in 2012, individual health center performance data is now available to the public on the HRSA web site. See: 14

Health Center EHR Adoption National and North Carolina, UDS 2011 Source: Uniform Data System, Goal: 50% of Health Centers use EHR at All Sites

North Carolina EHR Adoption UDS 2011 Data 16 HRSA, BPHC, Central Southeast Division (June 2012)

Demonstrates the quality of care provided in health centers and provides opportunity for continuous quality improvement. Positions health centers at an advantage for the changing health care landscape. Invests in the health center workforce resulting in reduced staff turnover and improved recruitment. Transforms patient care to help health centers achieve the three part aim of: Better care, Better health and communities, and Affordable care. Federal DHHS Priority o Goal: 25% of health centers PCMH recognized by 9/30/2013 o Goal: 40% of health centers PCMH recognized by 9/30/ Why PCMH?

18 Alignment of Health Center Program Requirements with PCMH Domains Section 330 Program RequirementNCQA PCMH Domain 1.Needs Assessment Identify and Manage Patient Populations 2.Required and Additional Services: Primary, preventive and enabling services Provide Self-Care Support and Community Resources 4.Accessible Hours of Operation/Locations 5.After Hours Coverage Enhance Access and Continuity 6.Hospital Admitting Privileges and Continuum of Care Plan and Manage Care 7.Quality Improvement/Assurance Plan Measure and Improve Performance 11.Collaborative Relationships 15.Program Data Reporting System Track & Coordinate Care Alignment of Health Center Requirements with PCMH Domains

FY 2011 PCMH Supplemental Funding Domains of Focus North Carolina Health Centers Enhance Access & Continuity Identify & Manage Patient Populations Plan and Manage Care Provide Self‐Care Support and Community Resources Track & Coordinate Care Measure and Improve Performance

2013 Health Center PCMH Recognition National and North Carolina Data as of February 2013 PCMH Recognized Includes: NCQA, Joint Commission, and AAAHC

PCMH Resources PCMH Comparison Chart – cies/pcmhrecognition.pdfhttp://bphc.hrsa.gov/policiesregulations/poli cies/pcmhrecognition.pdf Fact Sheet: Quality Improvement Initiatives Available to HRSA Supported Health Centers – cies/qioverview.pdfhttp://bphc.hrsa.gov/policiesregulations/poli cies/qioverview.pdf 21

2011 National and North Carolina Health Center Performance and Healthy People 2020 Goals Goal: 10+% of Health Centers Meet or Exceed HP 2020 Goals Source: 2011 UDS and Healthy People 2020

23 HRSA, BPHC, Central Southeast Division (June 2012)

24 HRSA, BPHC, Central Southeast Division (June 2012)

Program and Policy Updates 25

Change In Scope Enhanced and updated Change in Scope (CIS) Module released January 2013: Ensures CIS process fully aligns with scope of project policies. Consolidates information and questions that health centers must respond to into fewer checklists and forms. Improves CIS workflow to ensure appropriateness and readiness of CIS submission. Streamlines workflow for both Health Center and Project Officer review. See PAL : Alignment of EHB Change in Scope Module with Change in Scope Policy:

Operational Site Visits All health centers will receive an Operational Site Visit (OSV) at least once every three years conducted using the Health Center Site Visit GuideHealth Center Site Visit Guide 230 health centers received an operational site visit to date in CY ~400 OSVs planned for CY National Health Center TA Call on the OSV process planned for Spring BPHC is requesting feedback from health centers about their OSV experience through a follow up evaluation 3 months post site visit. Please share your experience!

Health Center Program Look-Alikes Oversight and monitoring functions of all current and newly- designated look-alikes transitioned from BPHC’s Office of Policy and Program Development to Project Officers in the Primary Health Care Divisions. Transition will allow HRSA to: - align strategies used to support and oversee all health centers; both grantees and look-alikes - identify and support look-alike technical assistance needs. See PAL : Look-Alike Program Update:

Recently Released Final Policies CY 2014 Requirements for Federal Tort Claims Act (FTCA) Medical Malpractice Coverage for Health Centers Alignment of EHB Change in Scope Module with Change in Scope Policy Look-Alike Program Update Uniform Data System Changes for Uniform Data System Reporting Changes for Look-Alikes Alignment of Communicable Diseases Screenings under Form 5A: Services Provided To Access these and other policies, visit: 29

Initiating and Maintaining Medicare FQHC Reimbursement CMS requires ALL permanent and seasonal sites within a health center’s approved scope of project to be enrolled INDIVIDUALLY in Medicare. Each site must also indicate its unique Medicare Billing Number (also known as a PTAN or CCN) on claims for all services rendered at that site. Please ensure that your health center has all of its correct Medicare Billings Numbers listed in EHB as soon as possible, for each of their permanent and seasonal sites. For more information about the requirements and process for enrolling sites in Medicare, review PAL

Anticipated Policy Topics FINAL Sliding Fee Discount Program PIN FINAL Governance PIN DRAFT Total Budget PIN DRAFT Financial Recovery Plan PAL DRAFT Subrecipients /Contracts PAL DRAFT Quality Improvement/Assurance PIN Draft policies open for comment will be posted at:

Funding Updates 32

Fiscal Year 2013 Spending Plan o $19 Million for Health Center New Access Points ( approximately 25 awards) o $20 million for Health Center Controlled Networks ( approximately 25 to 30 Awards) o $75 Million for School-Based Health Center Capital program ( approximately 150 awards) 33

Fiscal Year 2013 Continuation Funding Opportunities Health Centers: –FY 2013 Budget Period Progress Report (BPR) Technical Assistance: –FY 2013 Service Area Competition (SAC) Technical Assistance: Cooperative Agreements: –National –State/Regional Primary Care Associations 34

Fiscal Year 2012 Primary Care Association Requirements Statewide/Regional Health Center T/TA Activities A. Program Requirements Goal: % of Health Centers with No Program Conditions T/TA Focus Areas: Need Services – QI/QA Systems Management and Finance – Fiscal Operations/Systems Management and Finance – Workforce Recruitment and Retention Governance B. Performance Improvement Goals: % of Health Centers that Meet/Exceed Healthy People 2020 Goals on One or More Clinical Performance Measures % of Health Centers with PCMH Recognition % of Health Centers with Cost Increase Less than National Average % of Health Centers Financially Strong (No Going Concern Issues) T/TA Focus Areas: Clinical Performance Measures Financial Performance Measures 35

Fiscal Year 2012 Primary Care Association Requirements Statewide/Regional Program Assistance Workplan o Information on Available Resources o Annual T/TA Needs Assessment o Special Populations o Collaboration o Emergency Preparedness o Regional/Statewide Surveillance Analysis o Newly Funded Health Centers 36

Quality and Data Updates 37

Patient-Centered Medical/ Health Home Initiative (PCMHHI) Encourages and supports health centers to transform their practices and participate in the PCMHH recognition process to: –improve the quality of care and outcomes for health center populations; –increase access; and –provide care in a cost effective manner. HRSA/BPHC will cover recognition process fees and provide technical assistance resources for practice transformation. Participation is strongly encouraged and provides an opportunity for health centers to achieve PCMH recognition. For further information on the PCMHH Initiative: PCMHH Initiative PAL: BPHC Helpline: or BPHC PCMHH 38

FTCA Program FTCA Health Center Policy Manual o Primary source for information on FTCA grantees and related stakeholders o Consolidates, clarifies and synthesizes existing FTCA policy documents and statutory language Available at: Application Review/Deeming in EHB o 2013 Requirements for FTCA Deeming available in PAL : o For Programmatic of Technical TA on FTCA contact: Phone: 39

Technical Assistance Resources 40

Technical Assistance (TA) Resources National and state-based support for training and technical assistance: o National Cooperative Agreements o State/Regional Primary Care Associations o State Primary Care Offices Federal TA Support: o Project Officer o TA Calls/Trainings o Onsite Consultant Support o BPHC TA Website-New Search Engine Feature Added For more information visit the BPHC TA Website:

Bureau of Primary Health Care Help Line Single point of contact to assist grantees and stakeholders with information in the following areas: BHCMIS – System in EHB (Electronic Handbook) Health Center Quarterly Reporting (HCQR)/ARRA 1512 Reporting Uniform Data System (UDS) Federal Torts Claims Act (FTCA) for Health Centers and Free Clinics Phone: BPHC (2742) Available Monday to Friday (excluding Federal holidays), from 8:30 AM – 5:30 PM (ET), with extra hours available during high volume periods. 42

2011 Clinical Performance Data publicly available at: UDS Website: o Data analysis tools o Data download functionality UDS Grantee/State/National Summaries Health Center Trend Reports State and National Roll-up Reports Reporting and Training Resources UDS Mapper: HRSA has developed a mapping and support tool driven primarily from data within the UDS Webinar trainings on using Mapper functionality available: UDS Web Tools 43

ECRI risk management and patient safety resources are available to Health Center Program grantees and Free Clinics. Resources include: –Risk management courses –Continuing medical education (CME) credits at no cost to health care providers –Links to archived audio-conferences/webinars to supplement evidence-based risk management training –Guidance articles, self-assessment tools, ready-made training materials on patient safety, quality and risk management for the health center and free clinic setting –Risk & Safety E-news Visit: Risk Management and Patient Safety Web Resources 44

Primary Health Care and Public Health Leadership All Health Center and Primary Care Associations are encouraged to explore and participate in the following key HHS public health initiatives: Affordable Care Act and HRSA Programs Health Insurance Marketplace Health Centers Hire Veterans Challenge

National Quality Strategy HHS Action Plan to Reduce Racial and Ethnic Health Disparities mplete.pdf National Prevention Strategy ml National HIV/AIDS Strategy Primary Health Care and Public Health Leadership 46

National Oral Health Initiatives Behavioral Health Initiatives Healthy Weight Collaborative Million Hearts Campaign Text4baby Viral Hepatitis Initiative Primary Health Care and Public Health Leadership 47

Darryl Burnett Project Officer, Central Southeast Division U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care 5600 Fishers Lane Rm. PKLN/17-61 Rockville, MD Telephone:

Thank You! Questions? 49