HRSA Bureau of Primary Health CareAll-Programs Webcast

Tuesday, September 25, 2018

BPHC All-ProgramsSpeaker Notes: • Our Agenda for today:

• Month in Review – A look back at recent events and happenings

• Looking ahead – A look at some important things that are coming up

• On My Mind – I’ll share some other things that are on my mind including what’s coming in fiscal year 2019

• Q&A – We will have plenty of time for questions, which you can start asking questions now. Please use the “submit a question” button toward the top of the window under the HRSA logo.

AGEN

DA❶ Month in Review Recognizing HRSA Quality Leaders Updated Site Visit Protocol in Effect New Health Center Profiles Substance Use Disorder and Mental Health Expansion Awards Health Center Program Support

❷ Looking Ahead Virtual Job Fair HIV Care Integration

❸ On My Mind Fiscal Year Wrap-up and Update

❹ Q&A

2

Disaster Preparedness and RecoveryBefore we get into our agenda for today – we are thinking about our friends and colleagues in the Carolinas. I wanted to remind you that we have Disaster Preparedness and Recovery information on our website that we regularly update. You can find it right on the BPHC homepage and we’ll also share timely updates via our Digest newsletter and bulletins, as needed.

3

Month in ReviewRecognizing HRSA Quality Leaders

4

Month in ReviewUpdated Site Visit Protocol Now in Effect

Speaker’s Notes: HRSA’s revised Site Visit Protocol went into effect on Thursday, September 6. We will use this updated version to assess compliance onsite for all health center Operational Site Visits (OSVs). We also updated site visit resources, including the Progressive Action Conditions Library.

The changes align with the amended Health Center Program statute.

I also encourage you to check out our new video, which was included in the Primary Health Care Digest, featuring our Health Services Office Directors, Angela Powell and ErniaHughes, where they offer “Five Tips for a Successful OSV.”

Please also visit our website’s Program Requirements section to review the HRSA Health Center Program Compliance Manual and related resources like Frequently Asked Questions.

5

Month in ReviewNEW Health Center Profiles

Speaker Notes:Health Centers have asked for it and we are so happy to finally be able to share our new Health Center Profiles page.

This is where health centers can share their promising practices, so others can benefit from what’s worked for them.

You can find it on our quality improvement page. We started with two health centers and it will be great to watch this list grow.

6

Month in ReviewSUD-MH Awards

Speaker Notes: Last week, HRSA announced the release of the Expanding Access to Quality Substance Use Disorder and Mental Health Services (SUD-MH) awards. $352 million in funding will expand access to substance use disorder and mental health services at 1,232 community health centers across the nation. SUD-MH will expand access to integrated services by increasing personnel and enhancing infrastructure.

SUD-MH awards support HHS’s Five-Point Opioid Strategy, which launched last year to empower local communities on the frontlines to combat the crisis. Read more, including information on an upcoming webinar for awards recipients, in the Digest newsletter.

Substance Use Disorder and

Mental Health Services

$350 million

7

Looking AheadBehavioral Health Virtual Job Fair

Speaker Notes: [2:48 – 2:50 p.m. – 2 minutes]

HRSA will host it’s second Behavioral Health Virtual Job Fair on October 17.

The event will accommodate 100 actively recruiting clinical facilities. Secure a 15-minute time slot to discuss your health center’s benefits, clinical environment, and populations served, with a motivated audience of career-seeking behavioral health clinicians nationwide.

Employer registration for the October event closes tomorrow. Visit Jobfair.hrsa.gov for more information and to register.

The final Virtual Job Fair on November 28, 2018 celebrates National Rural Health Day. Interested health centers, located in rural areas, are encouraged to check Jobfair.hrsa.gov for the registration open.

Wednesday, October 17, 6:45 – 10:15 p.m. ETSpeak to thousands of behavioral health trainees and clinicians who are actively seeking employment:

• Psychiatrists• Psychologists• Licensed Clinical Social Workers• Licensed Professional Counselors• Marriage and Family Therapists• Nurses, specializing in psychiatry, mental or behavioral health • Physician Assistants, specializing in psychiatry, mental or

behavioral health

Register by visiting jobfair.hrsa.gov and follow instructions to register.

8

Month in ReviewHealth Center Program Support

Speaker Notes: • Effective September 24, the Health Center Program changed

the name of its helpline from BPHC Helpline to Health Center Program Support.

• There is a new, toll-free phone number: 877-464-4772 (TTY:877-897-9910).

• The hours of operation for Health Center Program Support are 7:00 a.m. to 8:00 p.m. ET, weekdays (except Federal holidays).

• “Same great service, different name!” Call for answers to your questions about the Health Center Program and Electronic Handbooks.

9

Looking Ahead HIV Care Integration

Speaker Notes: 2017 UDS data shows: 1,808,062 million patients were tested for HIV (increase from 2016 of 27%) (Table 6A, Line 21, Column b); 165,745 HIV Patients were served (increase from 2016 of 5%) at over 616,392 Visits (Table 6A, Line 1-2); 84.5% of HIV patients were linked to care (increase from 83.2% in 2016) (Estimated % of patients seen within 90 days of first diagnosis of HIV) (Table 6B, Line 20)

For the HIV care continuum, P4C health centers (79.1%) reported higher than the CDC national average (57.9%) for viral suppression of their HIV-positive patients.

Partnerships for Care (P4C) was a 3-year demonstration project (2014-2017) supported by the expand the provision of HIV prevention and care services within communities disproportionately impacted by HIV. 22 HRSA-funded health centers partnered with four CDC-funded state health departments in Florida, Maryland, Massachusetts, and New York to improve health outcomes across the HIV care continuum for PLWH, especially among racial and ethnic minorities.• HIV Testing: US Preventive Services Task Force recommends screening adolescents and adults aged 15-65 for HIV at least

once in their lifetime, regardless of risk. P4C health centers provided routine HIV testing to 77,347 patients aged 15-65 years in the first 2 years (2015-2016) who had never before been tested for HIV.

• HIV Care Continuum:• Linkage to Care within 90 days of HIV diagnosis• Retention in Care is defined as HIV medical patients from the previous (vs. current) year who had at least 2 HIV

medical visits in the current year• Prescribed Antiretroviral Treatment and Achieved Viral Suppression

The Southeast Practice Transformation Expansion Project (SEPTEP) is a 9-month HRSA project (September 2017-June 2018) funded by HRSA/BPHC’s in collaboration with the HIV/AIDS Bureau (HAB) The goal of SEPTEP is to advance HIV testing, linkageto care, and prevention at HRSA-funded health centers in the Southeast United States (Region 4), which has the nation’s highest rates of HIV diagnoses.

SEPTEP leverages lessons learned from BPHC’s P4C demonstration project and HAB’s AETC Program practice transformation projects. Health centers will receive HIV T/TA and practice transformation support from the Southeast AETC at Vanderbilt University to build the capacity of primary healthcare providers and teams caring for patients living with HIV and/or at highestrisk for HIV infection in underserved communities.• SEPTEP health centers have achieved PCMH recognition and are not dually funded through Part C of the Ryan White

HIV/AIDS Program• Coaching for practice transformation leadership includes a 2-day in-person workshop to (1) build core leadership skills in

communication and strategic planning to overcome implementation barriers and (2) learn best practices for HIV testing, prevention, and motivational interviewing. The workshop is followed by communities of practice to present cases, discuss lessons learned, and share strategies for overcoming barriers to HIV practice transformation.

• Additional resources can be found on HRSA/BPHC’s HIV Primary Care Integration webpage under Quality Improvement

↑ HIV testing by 27% to 1.8 million patients

84.5% of HIV patients were linked to care

Served 165,745 HIV patientsover 616,392 visits

Past: Partnerships for Care (P4C) Demonstration Project

Present: P4C Toolkit & Southeast Practice Transformation

Expansion Project (SEPTEP)

Future: Public Health Surveillance & Practice

Transformation

P4C Demonstration Project2014-2017

The 22 P4C health centers built and sustained their expanded HIV service delivery through:

• Optimized HIV testing, linkage to care, and pre-visit planning policies and procedures

• Continued partnerships with state health departments through joint case conferencing

82 84 6291 83 7693 89 79

0255075

100

1 2 3

% o

f HIV

Med

ical

Pat

ient

s HIV Care Continuum at 22 P4C Health Centers

Series1

Series2

Series3

10

On My Mind

11

Strategic Goals

Increase Access to Care

Advance Quality and Impact

OptimizeOperations

Health Center Program Mission: Improve the health of the nation’s underserved communities and vulnerable populations

12

National Impact

13

Increasing Access to Comprehensive CareCategory 2015 2016 2017 Δ 2015-2017Number of Sites 9,829 10,415 11,057 ˄ 12%Health Centers using Telehealth -- 523 600 --Total Health Center Patients 24,295,946 25,860,296 27,174,372 ˄ 12%

Medical 20,616,149 21,880,295 22,866,468 ˄ 11%Dental 5,192,846 5,656,190 6,116,732 ˄ 18%Mental Health 1,491,926 1,788,577 2,049,194 ˄ 37%Substance Use Disorder 117,043 141,569 168,508 ˄ 44%Vision 501,647 599,314 670,973 ˄ 34%Enabling 2,388,722 2,482,751 2,549,897 ˄ 07%

14

Patient-Centered Medical Home Recognition

Source: HRSA Accreditation and Patient-Centered Medical Home Report, 2018

15

Advancing Quality in Chronic Disease Management Controlled Diabetes

Percentage of Health Center Patients*

67% of diabetic health center patients have controlled HbA1c ≤ 9%,

exceeding national average of 57%**

1.22

1.411.52

70.2%

67.9%

67.1%

65.5%

66.0%

66.5%

67.0%

67.5%

68.0%

68.5%

69.0%

69.5%

70.0%

70.5%

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1 2 3

Perc

enta

ge o

f Pat

ient

s with

HbA

1c ≤

9%

Patie

nts w

ith H

bA1c

≤ 9

% (i

n M

illio

ns)

Series1 Series2

* Ranges are adjusted to account for outliers** NCQA: 2016 Medicaid-HMO, HbA1c <9.0%

16

Cost Savings in Diabetes Management

• Almost 280,000 (12%) of health center patients with diabetes either went to the emergency room or were hospitalized because of their diabetes.1

• Ambulatory expenditures are $1,656 less in health centers versus private care settings for patients with diabetes.2

• If health center patients with uncontrolled diabetes reduced their HbA1c by 1.25%, there is a potential to save more than $3.44 billion over a three-year span.3

Diabetes Related Health Concerns

1. 2014 Health Center Patient Survey 2. Richard, P. P Shin, T Beeson, et al. 2015 “Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States.” PLoS ONE 10(12)3. Fitch, K. B Pyenson, K Iwasaki. 2013 “Medical Claim Cost Impact of Improved Diabetes Control for Medicare and Commercially Insured Patients with Type 2 Diabetes.” J Manage Care Pharm. 19(8)

17

Advancing Quality in Chronic Disease Management Controlling High Blood Pressure

Percentage of Patients*

* indicates a change in operational definition due to CMS e-CQM alignment in 2016

NationalAverage †

201756.5%

† NCQA, Controlling High Blood Pressure: Medicaid HMO, 2016

Goal:61.2%

63.76

62.39

62.71

55 60 65

1

2

3

18

Integrating Behavioral Health and Primary Care

19

Offering Substance Use Disorder Services

20

Increasing Access to Medication Assisted Treatment

39,375

64,597

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

1 2

Patie

nts

Patients Receiving MAT

64%

1,700

2,973

0

500

1,000

1,500

2,000

2,500

3,000

3,500

1 2

Prov

ider

s

Providers* Eligible to Prescribe MAT

75%

376

472

0

50

100

150

200

250

300

350

400

450

500

1 2

Heal

th C

ente

rs

Health Centers Providing MAT

26%

21

Cost Savings

Source: Nocon, Robert S. et al. “Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings.” American Journal of Public Health, 2016 Nov; 106(11):1981-1989.

22

Modernizing the Uniform Data System (UDS)

Preliminary Reporting Environment • Access EHBs before

January 1st to begin entering and validating data early

Offline Tool Features• Enter UDS data offline• Timely data validation• Team-based data entry

New for 2018 UDS Reporting

Modernization GoalsReduce Reporting Burden

Provide enhanced UDS reporting capabilities that reduce burden and time to complete data entry.

Measure Impact

Improve the quality of UDS data to reflect improvements in patient-centered care and an evolving primary health care setting.

Promote Transparency

Provide a transparent decision-making process on UDS changes such as measure selection, information technology, and reporting improvements.

23

Health Center Capital Funding

In the past 10 years, HRSA has awarded more than $3.5 billion in Health Center Program Capital funding

In FY 2018, Congressional action provided $20 million in loan guarantee appropriations and increased loan guarantee authority, totaling nearly $890 million

24

Health Center WorkforceDiscipline 2015 2016 2017 ∆ 2015 - 2017

Physicians 11,867 12,419 12,894 ^9%Nurse Practitioners, Physician Assistants, Certified Nurse Midwives 10,332 11,485 12,621 ^22%Nurses 15,857 16,712 17,663 ^11%Other Medical Service Providers 29,572 31,838 34,120 ^15%Dentists 4,108 4,474 4,882 ^19%Other Dental Service Providers (Hygienists, Therapists, Aids, Techs) 10,450 11,668 12,920 ^24%Psychiatrists 591 688 754 ^28%Psychologists 708 822 869 ^23%Other Mental Health Providers 6,482 7,682 9,025 ^39%Substance Use Disorder Providers 960 1,163 1,416 ^48%Other Professional Services 1,301 1,413 1,511 ^16%Vision Service Providers 528 662 770 ^46%Enabling Service Providers 18,859 20,497 21,732 ^15%Total Facility and Non-Clinical Support Service Providers 67,962 74,304 79,691 ^17%TOTAL 188,852 207,656 223,840 ^19%

25

FY 2018 Funding Recap

* Estimated

26

Raising the Bar

Speaker Notes: As Jim mentioned, we [in this room] strive for continuous quality improvement

We are constantly looking for ways to do our work more effectively and efficiently – it’s driven from within

In addition, though, there are external forces that also impact our work and challenge us in new and exciting ways.

So I’m going to talk through the key policy and process updates stemming from the Bipartisan Budget Act and HHS Grants Policy Updates that impact the Health Center Program, particularly related to Compliance, Quality, and Assessing Need in communities.

The Bipartisan Budget Act of 2018 – or BBA – signed into law in February 2018, reauthorized spending for the Health Center Program and other Federal programs for fiscal years 2018 and 2019.

The BBA also amended certain sections of the Health Center Program statute by adding new requirements, changing some terminology, and increasing overall emphasis on the importance of maintaining compliance with Health Center Program requirements.

The BBA created a new authority to award supplemental grants to implement evidence-based models for increasing access to high-quality primary care services.

These could include, for example, models related to telehealth, behavioral health integration, and emerging public health issues such as the opioid epidemic.

At a very high level, the Bipartisan Budget Act and changes in Grants Policy impact how HRSA must assess Health Center Program compliance.

In addition, the Bipartisan Budget Act emphasizes the importance of health centers maintaining a state of full Program compliance.

It follows that these two areas of emphasis have direct impact on HRSA’s compliance assessment processes for health centers, namely: (1) our service area competition – or “SAC” for grantees and renewal of designation – or “RD” process for Look Alike health centers AND (2) operational site visits.

[PMA/Reimagine TPs]

External Drivers• HHS Grants Policy • President’s Management Agenda• HHS Reimagine• Bipartisan Budget Act

Health Center Program• Compliance• Quality• Assessing Need

27

Bipartisan Budget Act: Policy and Process UpdatesSpeaker Notes: Specifically, there are 6 key oversight-related policy and process updates related to:

1. Direct employment of health center CEO2. Demonstration of financial policies3. Focus on quality of care 4. Full compliance requirement for three-year project period5. One-year project periods for SAC or RD applicants with any condition at time of award

• First time SAC awardee • Not new, but underscored: Health centers cannot have three consecutive one-year

project periods

6. Independent assessment of SAC/RD applications – HRSA Reviewer who is not the Project Officer (Coach vs. Referee)

7. FAQs and resources available! https://bphc.hrsa.gov/programrequirements/pdf/hcp-statutory-changes.pdf

Health Center Program Statutory Changes

• Direct employment of health center CEO• Demonstration of financial policies• Focus on quality of care • Full compliance required for 3-year project period• One-year project periods for SAC or RD applicants

with any condition at time of award (not new)

28

Continuous Compliance: Resources and ToolsSpeaker Notes:

• Stakes are higher

• There are more supports and tools than ever

• Integrate compliance self-assessment into routine operations

Created the Manual

• Good news – completely transparent process – open book –lots of resources. You got this!

• Refer to Health Center Program Compliance Manual when completing SAC/RD application

• Prepare for Operational Site Visits using available resources• Resolve outstanding conditions prior to SAC/RD application• Seek HRSA staff support to address conditions (Coach)• We offer these resources to support transparency and

consistency in decision making

29

Continuous Compliance: CY 2018 OSV Results

Speaker Notes: To ensure clarity and transparency, each element within the Health Center Program Compliance Manual has a corresponding condition

About 5% (n=76) of 90-day conditions progressed to 60-day phase 39% of 60-day conditions are expanded conditions

Majority conditions from three chapterBoard AuthorityFinancial Management and ControlsSliding Feed Discount Program

• HRSA conducted 238 OSVs from January 1 to June 30, 2018

• 94% of OSV reports were completed on time (within 45 days of OSV)

Top OSV Compliance Findings by Requirement

1. Sliding Fee Discount Program2. Contracts and Sub awards3. Clinical Staffing4. Board Authority5. Billings and Collections

30

Service Area Needs Assessment Methodologies (SANAM)

Speaker Notes: Leverages public data sources to automatically calculate “need” in a way that is transparent, verifiable, and reduces health center burden

Provides an automated “need” score for a Zip Code and for health center service areas (i.e., group of ZIP Codes)Complements narrative assessment that describes particular “need” of target/special populations for health center servicesIdentifies areas of greatest “need” or “hot spots” to potentially target for NAPsAvailable to applicants on public website such as UDS Mapper

Potential future uses of SANAM:NAP need score (to potentially replace Need for Assistance Worksheet)Incentivize expansions into high need areas Support assessment of need in service area overlap and related decisions

Purpose: Explore the feasibility of a Service Area Needs Assessment Methodology that leverages public data to automatically calculate the “need” of a geographically defined service area in a way that is transparent, verifiable, and reduces application burden

Developed conceptual framework

Tested four prototypes for assessing “need” in the context of the Health Center Program

Shared framework and prototypes and sought feedback

Anticipate finalizing SANAM to implement in Fall 2018

31

Service Area Request for Information (RFI)

HRSA will share ideas to inform revisions or potential new policies

related to service area expansion/overlap for your input

CONSIDERATIONS

Proximity of a proposed new sites to closest another health center site

Distance of proposed new site from the requesting health center’s own

health center sites

Demonstrated performance/level of service prior to expansion

32

Looking AheadWe want your feedback!

Speaker Notes:

The HRSA BPHC Stakeholder Satisfaction Survey is coming soon!

This is your opportunity to let us know what we are doing well and areas where we can improve.

We take this feedback very seriously, we incorporated your feedback from last year’s survey. Some examples include: EHB modernization efforts and release of the new Compliance Manual and Site Visit Protocol.

If your organization does not receive a survey invitation, send an email to BPHCReviews@hrsa.gov

Thank you in advance for taking the time to help us improve the Health Center Program!

• HRSA BPHC Stakeholder Satisfaction Survey coming soon.

• Help BPHC continue to improve the Health Center Program by taking the survey!

• Can’t find your survey link? Email BPHCReviews@hrsa.gov

33

Q&AThank you for participating!

To ask a question, use the “submit a question” button at the top of the window under the HRSA logo

You can also dial 1-888-972-9249Use the passcode: “Webcast”

Please then press *1 to enter the question queuePlease mute your computer speakers when asking a question

Please remember to complete today’s survey

34

Connect with HRSA

To learn more about our agency, visit

www.HRSA.gov

Sign up for the HRSA eNews

FOLLOW US:

35