Federally qualified health centers and private practice performance on ambulatory care measures

Does the Regulatory Environment Affect Nurse Practitioners' Patterns of Practice or Quality of Care in Health Centers?

OBJECTIVE

To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals.

DATA SOURCES/STUDY SETTING

The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs.

STUDY DESIGN

Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design.

DATA COLLECTION/EXTRACTION METHODS

Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items.

PRINCIPAL FINDINGS

After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states.

CONCLUSIONS

Findings do not support a quality-scope of practice relationship.

Characteristics and Service Use of Medicare Beneficiaries Using Federally Qualified Health Centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) provide primary care for millions of Americans, but little is known about Medicare beneficiaries who use FQHCs.

OBJECTIVE

To compare patient characteristics and health care service use among Medicare beneficiaries stratified by FQHC use.

RESEARCH DESIGN

Cross-sectional analysis of 2011 Medicare fee-for-service beneficiaries aged 65 years and older.

SUBJECTS

Subjects included beneficiaries with at least 1 evaluation and management (E&M) visit in 2011, categorized as FQHC users (≥1 E&M visit to FQHCs) or nonusers living in the same primary care service areas as FQHC users. Users were subclassified as predominant if the majority of their E&M visits were to FQHCs.

MEASURES

Demographic characteristics, physician visits, and inpatient care use.

RESULTS

Most FQHC users (56.6%) were predominant users. Predominant and nonpredominant users, compared with nonusers, markedly differed by prevalence of multiple chronic conditions (18.2%, 31.7% vs. 22.7%) and annual mortality (2.8%, 3.8% vs. 4.0%; all P<0.05). In adjusted analyses (reference: nonusers), predominant users had fewer physician visits (RR=0.81; 95% CI, 0.81-0.81) and fewer hospitalizations (RR=0.84; 95% CI, 0.84-0.85), whereas nonpredominant users had higher use of both types of service (RR=1.18, 95% CI, 1.18-1.18; RR=1.09, 95% CI, 1.08-1.10, respectively).

CONCLUSIONS

Even controlling for primary care delivery markets, nonpredominant FQHC users had a higher burden of chronic illness and service use than predominant FQHC users. It will be important to monitor Medicare beneficiaries using FQHCs to understand whether primary care only payment incentives for FQHCs could induce fragmented care.

Patient Experiences with Care Differ with Chronic Care Management in a Federally Qualified Community Health Center

This study compares patient experience among practices that vary in adoption of the chronic care management (CCM) dimension of the patient-centered medical home (PCMH) model that focuses on care coordination and management of chronic diseases. Study participants were 2903 adult patients (ages 18 years or older) at 14 primary care centers in California. Seven of the sites were classified as high (more CCM) and the other 7 low on a CCM index. Hypotheses were tested using ordinary least squares regression models. After adjusting for the number of providers at the sites, high CCM scores were associated with significantly better overall ratings of providers, provider communication, follow-up on test results, and willingness to recommend the provider (differences of 5.82, 6.85, 9.81, and 4.56, respectively on the 0-100 scale scores). The results of this study provide support for the value of the PCMH for patient experiences with care.

Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians' Offices

OBJECTIVE

To examine adherence to guideline-concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices.

DATA SOURCES/STUDY SETTING

National Ambulatory Medical Care Survey from 2006 to 2010.

STUDY DESIGN

We examined four guideline-concordant treatment practices: initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHC with private physicians' offices overall and by payer group.

DATA COLLECTION/EXTRACTION METHODS

We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices.

PRINCIPAL FINDINGS

Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 percent CI: 0.6-1.9), whereas Medicaid patients at private physicians' offices were less likely to receive a new medication (AOR 0.3, 95 percent CI: 0.1-0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95 percent CI: 0.4-0.9). Thiazide use for patients was similar in both settings (AOR 0.8, 95 percent CI: 0.4-1.7). Use of aldosterone antagonists was too rare (2.1 percent at CHCs and 1.5 percent at private clinics) to allow for statistically reliable comparisons.

CONCLUSIONS

Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.

Quality Health Care for Homeless Children: Achieving the AAP Recommendations for Care of Homeless Children and Youth

BACKGROUND

We assessed whether and how health care organizations serving homeless pediatric patients meet recommendations issued by the American Academy of Pediatrics (AAP).

METHODS

We conducted a web-based survey of Health Care for the Homeless (HCH) Program grantees serving children.

RESULTS

Of 169 grantees, 77 (46%) responded. All organizations reported connecting patients to specialty services. Nearly all reported screening for homelessness (90%), facilitating Medicaid enrollment (90%), connecting patients to benefits (94%), addressing underlying causes of homelessness (83%), assisting with transportation (83%), and knowing about the causes of homelessness (76%). Fewer reported integrating comprehensive care into acute visits (61%) or having medical-legal partnerships (57%). Federally qualified health center status was associated with meeting more recommendations. We described barriers and facilitators to meeting recommendations.

DISCUSSION

Health care organizations serving homeless children largely meet AAP recommendations, but integrating comprehensive care into acute visits remains an area for improvement. Disseminating best practices may support guideline adherence.

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [-4.40 percentage points; 95 % confidence intervals (CI) -5.80, -3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

Use of Federally Qualified Health Centers and Potentially Preventable Hospital Utilization Among Older Medicare-Medicaid Enrollees

Using Medicare claims data from 2007 to 2010, we sought to determine whether dual eligibles 65 years and older who utilize federally qualified health centers (FQHCs) have lower rates of ambulatory care-sensitive hospitalizations and emergency department visits compared with nonusers. We found that FQHC use is associated with increased ambulatory care-sensitive hospitalization rates for whites and other races, but a decrease among blacks. Depending on race, FQHC use is associated with an increase of 24 to 43 ambulatory care-sensitive emergency department visits per thousand persons annually. More research is needed to understand why FQHC use is associated with these outcomes among dual eligibles.

Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings

OBJECTIVES

To compare health care use and spending of Medicaid enrollees seen at federally qualified health centers versus non-health center settings in a context of significant growth.

METHODS

Using fee-for-service Medicaid claims from 13 states in 2009, we compared patients receiving the majority of their primary care in federally qualified health centers with propensity score-matched comparison groups receiving primary care in other settings.

RESULTS

We found that health center patients had lower use and spending than did non-health center patients across all services, with 22% fewer visits and 33% lower spending on specialty care and 25% fewer admissions and 27% lower spending on inpatient care. Total spending was 24% lower for health center patients.

CONCLUSIONS

Our analysis of 2009 Medicaid claims, which includes the largest sample of states and more recent data than do previous multistate claims studies, demonstrates that the health center program has provided a cost-efficient setting for primary care for Medicaid enrollees.

Toward a More Complete Picture of Outpatient, Office-Based Health Care in the U.S

The healthcare system in the U.S., particularly outpatient, office-based care, has been shifting toward service delivery by advanced practice providers, particularly nurse practitioners (NPs) and physician assistants (PAs). The National Ambulatory Medical Care Survey (NAMCS), conducted by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention, is the leading source of nationally representative data on care delivered by office-based physicians. This paper first describes NAMCS, then discusses key NAMCS expansion efforts, and finally presents major findings from two exploratory studies that assess the feasibility of collecting data from NPs and PAs as sampled providers in NAMCS. The first NAMCS expansion effort began in 2006 when the NAMCS sample was expanded to include community health centers and started collecting and disseminating data on physicians, NPs, PAs, and nurse midwives in these settings. Then, in 2013, NCHS included workforce questions in NAMCS on the composition and clinical tasks of all healthcare staff in physician offices. Finally, in 2013-2014, NCHS conducted two exploratory studies and found that collecting data from NPs and PAs as sampled providers in NAMCS is feasible. However, modifications to the current NAMCS procedures may be necessary, for example, changing recruitment strategies, visit sampling procedures, and physician-centric survey items. Collectively, these NCHS initiatives are important for healthcare research, practice, and policy communities in their efforts toward providing a more complete picture of the changing outpatient, office-based workforce, team-based care approach, and service utilization in the U.S.

Affordable Care Act Impact on Community Health Center Staffing and Enrollment: A Cross-Sectional Study

Over 500 000 Washingtonians gained health insurance under the Affordable Care Act (ACA). As more patients gain insurance, community health centers (CHCs) expect to see an increase in demand for their services. This article studies the CHCs in Washington State to examine how the increase in patients has been impacting their workload and staffing. We found a reported mean increase of 11.7% and 5.4% in new Medicaid and Exchange patients, respectively. Half of the CHCs experienced large or dramatic workload impact from the ACA. Our findings suggest that CHCs need further workforce support to meet the expanding patient demand.

Patient Experience in Health Center Medical Homes

The Human Resource and Services Administration, Bureau of Primary Health Care Health Center program was developed to provide comprehensive, community-based quality primary care services, with an emphasis on meeting the needs of medically underserved populations. Health Centers have been leaders in adopting innovative approaches to improve quality care delivery, including the patient centered medical home (PCMH) model. Engaging patients through patient experience assessment is an important component of PCMH evaluation and a vital activity that can help drive patient-centered quality improvement initiatives. A total of 488 patients from five Health Center PCMHs in south Florida were surveyed in order to improve understanding of patient experience in Health Center PCMHs and to identify quality improvement opportunities. Overall patients reported very positive experience with patient-centeredness including being treated with courtesy and respect (85 % responded “always”) and communication with their provider in a way that was easy to understand (87.7 % responded “always”). Opportunities for improvement included patient goal setting, referrals for patients with health conditions to workshops or educational programs, contact with the Health Center via phone and appointment availability. After adjusting for patient characteristics, results suggest that some patient experience components may be modified by educational attainment, years of care and race/ethnicity of patients. Findings are useful for informing quality improvement initiatives that, in conjunction with other patient engagement strategies, support Health Centers’ ongoing transformation as PCMHs.

Younger Dual-Eligibles Who Use Federally Qualified Health Centers Have More Preventable Emergency Department Visits, but Some Have Fewer Hospitalizations

OBJECTIVE

To determine whether younger dual-eligibles receiving care at federally qualified health centers (FQHCs) have lower rates of ambulatory care sensitive (ACS) hospitalization and emergency department (ED) visits.

DATA SOURCES

We used the 100% Medicare Part A and Part B institutional claims from 2007 to 2010 for dual-eligibles younger than 65 years, enrolled in traditional fee-for-service Medicare, who received care at an FQHC or lived in a primary care service area with an FQHC.

METHODS

Our cross-sectional analysis used negative binomial regressions to model ACS hospitalizations and ED visits as a function of prior year FQHC use. The model adjusted for beneficiary age, gender, race, and chronic diseases, as well as county fixed effects, time trends, and race-FQHC use interactions.

RESULTS

FQHC use is associated with a decrease in ACS hospitalization rates for whites (2.8 per 1000 persons), but an increase among blacks (2.5 per 1000 persons). FQHC use is also associated with an increase in ACS ED visits, from 27 to 33 more visits per 1000 persons per year, depending on patient race.

CONCLUSIONS

ACS hospital use is higher for FQHC users than nonusers, but white FQHC users have fewer ACS hospitalizations. More research is needed to understand how this relationship varies within and between centers.

Receipt of Preventive Services After Oregon's Randomized Medicaid Experiment

INTRODUCTION

It is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S., primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon's 2008 randomized Medicaid expansion ("Oregon Experiment") on receipt of 12 preventive care services in community health centers using electronic health record data.

METHODS

Demographic data from adult (aged 19-64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008-2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012-2014; analysis performed in 2014-2015).

RESULTS

Intent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for 8 of 12 assessed preventive services. In intent-to-treat analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography).

CONCLUSIONS

Rates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations.

Adaptation of an Evidence-Based Colorectal Cancer Screening Program Using the Consolidated Framework for Implementation Research

INTRODUCTION

Federally Qualified Health Centers (FQHCs) provide primary care to low-income and uninsured patients in the United States. FQHCs are required to report annual measurements and provide evidence of improvement for quality measures; effective methods to improve quality in FQHCs are needed. Systems of Support (SOS) is a proactive, mail-based, colorectal cancer screening program that was developed and tested in an integrated health care system. The objective of this study was to adapt SOS for use in an FQHC system, guided by the Consolidated Framework for Implementation Research (CFIR).

METHODS

We conducted qualitative semi-structured interviews in 2014 with organizational leadership, medical staff, and nursing staff to identify facilitators of and barriers to implementation of SOS in an FQHC system. The interview guide was based on the CFIR framework. Interview transcripts were analyzed using Template Analysis. We adapted SOS and planned implementation strategies to address identified barriers.

RESULTS

Facilitators of implementation of SOS were previous quality improvement experience and engagement of clinic and administrative leadership. Barriers to implementation were a more diverse patient population, a decentralized administrative structure, and communication challenges throughout the organization. Program adaptations focused on patient instructions and educational materials as well as elimination of follow-up phone calls. Implementation strategies included early and frequent engagement with organizational leadership and a smaller pilot program before organization-wide implementation.

CONCLUSIONS

Use of CFIR identified facilitators of and barriers to implementation of the evidence-based colorectal cancer screening program. Program adaptations and implementation strategies based on this study may generalize to other FQHC systems that are considering implementation of a proactive, mail-based colorectal cancer screening program.

Community health centers and primary care access and quality for chronically-ill patients - a case-comparison study of urban Guangdong Province, China

Objective

Reform of the health care system in urban areas of China has prompted concerns about the utilization of Community Health Centers (CHC). This study examined which of the dominant primary care delivery models, i.e., the public CHC model, the ‘gate-keeper’ CHC model, or the hospital-owned CHC models, was most effective in enhancing access to and quality of care for patients with chronic illness.

Methods

The case-comparison design was used to study nine health care organizations in Guangzhou, Dongguan, and Shenzhen cities within Guangdong province, China. 560 patients aged 50 or over with hypertension or diabetes who visited either CHCs or hospitals in these three cities were surveyed by using face-to-face interviews. Bivariate analyses were performed to compare quality and value of care indicators among subjects from the three cities. Multivariate analyses were used to assess the association between type of primary care delivery and quality as well as value of chronic care after controlling for patients’ demographic and health status characteristics.

Results

Patients from all three cities chose their current health care providers primarily out of concern for quality of care (both provider expertise and adequate medical equipment), patient-centered care, and insurance plan requirement. Compared with patients from Guangzhou, those from Dongguan performed significantly better on most quality and value of care indicators. Most of these indicators remained significantly better even after controlling for patients' demographic and health status characteristics. The Shenzhen model (hospital-owned and -managed CHC) was generally effective in enhancing accessibility and continuity. However, coordination suffered due to seemingly duplicating primary care outpatients at the hospital setting. Significant associations between types of health care facilities and quality of care were also observed such that patients from CHCs were more likely to be satisfied with traveling time and follow-up care by their providers.

Conclusion

The study suggested that the Dongguan model (based on insurance mandate and using family practice physicians as ‘gate-keepers’) seemed to work best in terms of improving access and quality for patients with chronic conditions. The study suggested adequately funded and well-organized primary care system can play a gatekeeping role and has the potential to provide a reasonable level of care to patients.

Service Delivery and Patient Outcomes in Ryan White HIV/AIDS Program-Funded and -Nonfunded Health Care Facilities in the United States

IMPORTANCE

Outpatient human immunodeficiency virus (HIV) health care facilities receive funding from the Ryan White HIV/AIDS Program (RWHAP) to provide medical care and essential support services that help patients remain in care and adhere to treatment. Increased access to Medicaid and private insurance for HIV-infected persons may provide coverage for medical care but not all needed support services and may not supplant the need for RWHAP funding.

OBJECTIVE

To examine differences between RWHAP-funded and non-RWHAP-funded facilities and in patient outcomes between the 2 systems.

DESIGN, SETTING, AND PARTICIPANTS

The study was conducted from June 1, 2009, to May 31, 2012, using data from the 2009 and 2011 cycles of the Medical Monitoring Project, a national probability sample of 8038 HIV-infected adults receiving medical care at 989 outpatient health care facilities providing HIV medical care.

MAIN OUTCOMES AND MEASURES

Data were used to compare patient characteristics, service needs, and access to services at RWHAP-funded vs non-RWHAP-funded facilities. Differences in prescribed antiretroviral treatment and viral suppression were assessed. Data analysis was performed between February 2012 and June 2015.

RESULTS

Overall, 34.4% of facilities received RWHAP funding and 72.8% of patients received care at RWHAP-funded facilities. With results reported as percentage (95% CI), patients attending RWHAP-funded facilities were more likely to be aged 18 to 29 years (8.5% [7.4%-9.5%] vs 5.0% [3.9%-6.2%]), female (29.2% [27.2%-31.2%] vs 20.1% [17.0%-23.1%]), black (47.5% [41.5%-53.5%] vs 25.8% [20.6%-31.0%]) or Hispanic (22.5% [16.4%-28.6%] vs 12.9% [10.6%-15.2%]), have less than a high school education (26.1% [24.0%-28.3%] vs 10.9% [8.7%-13.1%]), income at or below the poverty level (53.6% [50.3%-56.9%] vs 23.9% [19.7%-28.0%]), and lack health care coverage (25.0% [21.9%-28.1%] vs 6.1% [4.1%-8.0%]). The RWHAP-funded facilities were more likely to provide case management (76.1% [69.9%-82.2%] vs 15.4% [10.4%-20.4%]) as well as mental health (64.0% [57.0%-71.0%] vs 18.0% [14.0%-21.9%]), substance abuse (33.6% [27.0%-40.2%] vs 12.0% [8.0%-16.0%]), and other support services; patients attending RWHAP-funded facilities were more likely to receive these services. After adjusting for patient characteristics, the percentage prescribed ART antiretroviral therapy, reported as adjusted prevalence ratio (95% CI), was similar between RWHAP-funded and non-RWHAP-funded facilities (1.01 [0.99-1.03]), but among poor patients, those attending RWHAP-funded facilities were more likely to be virally suppressed (1.09 [1.02-1.16]).

CONCLUSIONS AND RELEVANCE

A total of 72.8% of HIV-positive patients received care at RWHAP-funded facilities. Many had multiple social determinants of poor health and used services at RWHAP-funded facilities associated with improved outcomes. Without facilities supported by the RWHAP, these patients may have had reduced access to services elsewhere. Poor patients were more likely to achieve viral suppression if they received care at a RWHAP-funded facility.

Comparing the Cost of Caring for Medicare Beneficiaries in Federally Funded Health Centers to Other Care Settings

OBJECTIVE

To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics.

DATA SOURCES/STUDY SETTINGS

Part A and B fee-for-service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC.

STUDY DESIGN

We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects.

DATA COLLECTION

Data were obtained from the Centers for Medicare & Medicaid Services.

PRINCIPAL FINDINGS

Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs.

CONCLUSIONS

HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients.

The Role of Federally Qualified Health Centers in Delivering Family Planning Services to Adolescents

PURPOSE

The purpose of this article was to examine the role of community health centers (CHCs) in providing comprehensive family planning services to adolescents, looking at the range of services offered and factors associated with provision of these services.

METHODS

This study employed a mixed methods approach comprising a national survey of CHCs and six in-depth case studies of health centers to examine the organization and delivery of family planning services. We developed an adolescent family planning index comprising nine family planning services specifically tailored to adolescents. We analyzed the influence of state-level family planning policies, funding for adolescents, and organizational characteristics on the provision of these services in CHCs. The case studies identified barriers to the provision of family planning to adolescent patients.

RESULTS

The survey found substantial variation in the provision of family planning services at CHCs, with a mean of 6.33 out of a maximum score of 13 on the family planning adolescent services index. Title X funding and location within a favorable state policy environment were significantly associated with higher scores on the family planning adolescent services index (p value < .001 and .002, respectively). Case studies revealed barriers to adolescent family planning, including lack of funding, lack of knowledge, and limitations on school-based clinical services.

CONCLUSIONS

CHCs have the opportunity to play a significant role in providing high-quality family planning to low-income, medically underserved adolescents. Additional funding, resources, and a favorable policy climate would further improve CHCs' ability to serve the family planning needs of this special patient population.

Understanding sexually transmitted infection screening and management in Indiana community health centers

BACKGROUND

The role of community health centers (CHCs) in preventive health care is central to health reform, yet little is known about how CHCs identify and manage sexually transmitted infections (STIs).

METHODS

A survey of Indiana CHCs from April to May 2013 measured reported STI services, clinic expectations for STI testing and management, barriers to screening and management, and partner services. Reported practices were compared with current Centers for Disease Control and Prevention (CDC) guidelines for STI testing in clinical settings.

RESULTS

Although most CHCs reported screening for syphilis (75.0%), chlamydia, and gonorrhea (85.7%), screening generally did not reflect CDC guidelines. Chlamydia and gonorrhea testing was provided primarily at patient request or when symptomatic by 67.9% of CHCs. Syphilis testing at 67.9% of CHCs reflected CDC guidelines for adults 65 years or younger and at 53.6% for first-trimester pregnant women. Chlamydia and gonorrhea screening reflected CDC guidelines for 17.9% of CHCs for gay/bisexual men and 60.9% for first-trimester pregnant women. One-third (35%) of CHCs reported not knowing the expectation for screening pregnant women and gay/bisexual men.

CONCLUSIONS

It is likely that CHCs are not aware of patient sexual health risks because standard of care screening was observed only for gonorrhea and chlamydia during the first trimester and for syphilis testing when symptoms were present. As CHCs increase their role in preventive care with the implementation of the Affordable Care Act, focus must be upon clinician awareness of patient sexual health and training to identify and manage STIs in their patient populations.

Nurse practitioners, physician assistants, and physicians in community health centers, 2006-2010

PURPOSE

Community health centers (CHCs) fill a vital role in providing health care to underserved populations. This project compares characteristics of patient visits to nurse practitioners (NPs), physician assistants (PAs), and physicians in CHCs.

METHODS

This study analyzes 2006-2010 annual survey data from the National Ambulatory Medical Care Survey CHC sample, a representative national sample of CHC providers and patient visits. We examine trends in provider mix in CHCs and compare NPs, PAs, and physicians with regard to patient and visit attributes. Survey weights are used to produce national estimates.

RESULTS

There were, on average, 36,469,000 patient visits per year to 150,100 providers at CHCs; 69% of visits were to physicians, 21% were to NPs, and 10% were to PAs. Compared to visits to NPs, visits made to physicians and PAs tended to be for chronic disease treatment and for patients whom they serve as primary care providers. Visits to NPs tended to be for preventive care.

CONCLUSIONS

This study found more similarities than differences in characteristics of patients and patient visits to physicians, NPs, and PAs in CHCs. When statistical differences were observed, NP patient and visit characteristics tended to be different from those of physicians.

IMPLICATIONS

Results provide detailed information about visits to NPs and PAs in a setting where they constitute a significant portion of providers and care for vulnerable populations. Results can inform future workforce approaches.

Chronic kidney disease care in the US safety net

The US Health Care System provides a patchwork of services, known as the safety net, for the uninsured, underinsured, and indigent populations who would otherwise have little access to health care services. Individuals who rely on safety-net facilities are from racial/ethnic minority groups, have low socioeconomic status, and often have low health literacy and/or limited English proficiency. They shoulder a disproportionate burden of CKD in the United States and experience excess CKD-associated morbidity and mortality. Suboptimal delivery of CKD care may be contributing and is an area of active translational research. Several initiatives that show promise in improving safety-net CKD care delivery include those that enhance diagnostic and management skills of primary care providers, rely on comprehensive care management programs led by nonphysicians, and leverage technology to enhance patient access to virtual nephrology expertise. Uncovering better ways to translate scientific evidence into practice for vulnerable patients with CKD is a formidable challenge that will require national surveillance of CKD quality measures across diverse ambulatory health systems, including safety nets. Only then will the nephrology community be to identify and share best practices to enhance health and mitigate disparities of care among patients with CKD.

Innovation in the safety net: integrating community health centers through accountable care

BACKGROUND

Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers.

OBJECTIVE

This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers.

DESIGN

Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013).

PARTICIPANTS

One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs.

MAIN MEASURES

Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software.

KEY RESULTS

Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise.

CONCLUSIONS

A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.

No evidence that primary care physicians offer less care to Medicaid, community health center, or uninsured patients

The Affordable Care Act increases US investment in Medicaid and community health centers, yet many people believe that care in such safety-net programs is substandard. Using data from more than 31,000 visits to primary care physicians in the period 2006-10, we examined whether the length or content of a visit was different for safety-net patients-those insured by Medicaid, those who are uninsured, and those seen in a community health center-compared to patients with private insurance. We found no significant differences in the average length of a primary care visit or in the likelihood of a patient's receiving preventive health counseling. Medicaid patients received more diagnostic and treatment services, and uninsured patients received fewer services, compared to privately insured patients, but the differences were small. This analysis indicates that length and content of primary care visits are comparable for safety-net and other patients. The main factors that contribute to differences in visit length and content are patients' health needs and the type of visit involved.

Caring for the disadvantaged: the role of physician assistants

OBJECTIVE

We investigated community health centers (CHCs) and the roles of physician assistants (PAs) within them. Our goals were to broadly describe PA practice characteristics within CHCs, to explore why PAs work in CHCs, and to understand patient perspectives of PAs.

METHODS

We evaluated 10 CHCs in Texas (5 urban and 5 rural), using an ethnographic approach to examine attitudes and beliefs of PAs, medical staff, and patients.

RESULTS

Nine of the 10 clinics used PAs interchangeably with physicians, and most medical staff and patients perceived few differences between them. Patients view all providers as highly effective and genuinely concerned for their patients.

CONCLUSIONS

We found that clinicians and staff believe in the work they do, report that they function as a team, and seem to like their roles. It appears that working with the medically underserved and economically disadvantaged enables PAs to thrive.

Health care utilization and receipt of preventive care for patients seen at federally funded health centers compared to other sites of primary care

OBJECTIVE

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.

DATA SOURCES

A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004-2008).

STUDY DESIGN

HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.

PRINCIPAL FINDINGS

Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.

CONCLUSIONS

Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.

Diabetes care quality is highly correlated with patient panel characteristics

INTRODUCTION

Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs).

METHODS

Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined.

RESULTS

Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators.

CONCLUSIONS

Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.