P260nh pch grantimpactreport 111914

Partnership for Community Health 2013 Report on Grant Funding

An initiative of

Neighborhood Health Plan

and Partners HealthCare

to support Community

Health Centers

The Partnership for Community Health Grant Program supports the Community Health Centers (CHCs) in Massachusetts by funding their ongoing efforts to:

› increase access to high-quality health care

› promote health equity

› organize comprehensive and cost-effective care for patients in their communities

The program takes a collaborative and results-based approach, enabling CHCs to meet the evolving needs of their patients, while also driving systemic change in community health.

Program Vision

Table of ContentsExecutive Summary........................................................................................ 2

2013 Funding Eligibility and Target Areas ......................................................... 5

2013 Results

IT Reporting Capacity: Technology for Better Outcomes ............................... 6

Meaningful Use Implementation: Incentives for Better Care ....................... 14

Coding Training: Improving Patient Records and Reimbursement ............... 24

Training and Capacity Building for Performance Improvement .................... 30

Looking to the Future .................................................................................. 38

Appendix .................................................................................................... 41

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2 Executive Summary

In and beyond Massachusetts, health care stakeholders – providers, hospitals, insurers and others – seek ways to reduce costs, deliver better quality care with more coordination, and create overall value in health care benefits. The Partnership for Community Health (PCH or “the Partnership”), an initiative of Neighborhood Health Plan (NHP), Partners HealthCare (Partners), in collabora-tion with the Massachusetts League of Community Health Centers (“the League”), was created with just those goals in mind. The Partnership is supporting the state’s commu-nity health centers (CHCs) in their continued efforts to reduce access barriers, promote health equity and organize care for patients in their communities.

As part of a shared commitment to supporting CHCs, PCH has created an unprecedented funding partnership that will provide grants for projects specifically focused on community health center infrastructure improvements. In awarding these grants, NHP and Partners sought input from health center leaders and will continue to do so in subsequent grants so that PCH can create meaningful, sustainable investment in the CHCs. All Massachusetts community health centers that are organizational members of the League are eligible for the PCH grants.

NHP and Partners are deeply committed to the belief that CHCs are the cornerstone of an accessible, high-quality, and cost-effective health care delivery system, particularly for underserved communities. The Partnership grant program is vital in the effort to enhance and ensure support for community health centers throughout Massachusetts.

In 2013, the first year of funding, CHCs have reported process improvements and effi-ciencies that amount to positive impacts for the patients they serve. A total of $4.225 million was awarded in non-competitive grants to all 49 organizational League members to help them prepare for Patient-Centered Medical Home accreditation, state payment reform and federal health reform requirements.

Partnership grants were awarded in 2013 for a one-time need in four key areas all aimed toward helping CHCs assess and act on opportunities presented through payment reform. Projects in each of these areas were funded and implemented in this first year. As a result of these grants, community health centers reported the following range of improvements in

Executive Summary

3Executive Summary

their workflows, Electronic Medical Record (EMR) infrastructure and patient health management capabilities:

IT Reporting Capacity – New data and reporting tools have helped CHCs identify and outreach to patients who need important health screenings and immunizations as well as focused hospital follow-up and specialized care management. With more personalized care, patients feel more engaged and empowered to manage complicated health conditions.

Meaningful Use Implementation – Through a sustained focus on the “meaningful use” of technology, CHCs have realized operational efficiencies, such as e-prescribing and elec-tronic charting, which lower patient wait times and increase patient satisfaction. Patients also benefit from new online communication tools, like patient portals, to more easily com-municate with doctors and coordinate care.

Coding Training – Improved coding compliance has helped CHCs to refine outreach to those with complex care needs, increasing the quality of care for the most vulnerable patients.

Training and Capacity Building for Performance Improvement – The quality improvement projects have decreased wait times, increased satisfaction, and have improved individualized interventions for CHC patients.

Going forward, the Partnership for Community Health will build on this progress. The Partnership envisions that future grants will provide multiyear funding through a competitive process and the opportunity to create effective collaborations across CHCs. This will begin with PCH Excellence and Innovation grants, targeting two-year projects with a specific focus in these areas: data and decision support, operational improvement, shared services, and engagement and communication.

In this time of reform, it is essential that community health centers continue to expand on reporting tools and resources to improve patient experiences and the health of their populations, and reduce the cost of care. The PCH 2013 grant round helped community health centers build the infrastructure to improve operations and clinical outcomes and reach specific populations for more intensive care – to better serve vulnerable communities.

The report that follows describes PCH grant projects implemented in 2013, and shares outcomes as reported by the health centers that were made possible through the Partnership investment.

4 Executive Summary

CHCs have increased their capacity to align quality goals with national reform initiatives and incentives.

• Six Massachusetts health centers achieved Patient-Centered Medical Home accredita-tion from the National Committee for Quality Assurance (NCQA).

• Six health centers engaged in activities that are core to the medical home clinical model, including, increasing capacity for clinical reporting and training for staff.

• Six health centers met CMS Meaningful Use objectives.

• Thirteen health centers utilized grant support to build the necessary infrastructure to qualify for federal incentive payments.

The Partnership for Community Health Grant Results

CHCs have increased preventive care in seven areas:

• Immunizations

• Mammography

• Well child visits

• Retinal screenings

• LDL screenings

• PAP smear

• Colonoscopy protocol compliance

Eleven CHCs reported significant gains on important care management outcomes, including:

• Hospital care follow-up

• Care for persistent asthmatics

• Blood pressure control

5The Partnership for Community Health: 2013 Funding Eligibility and Target Areas

In 2013, the first year of funding, the Partnership looked to provide meaningful support for projects that would enhance and further develop infrastructure improvements at CHCs in Massachusetts.

Funding Eligibility

All CHCs with organizational League membership were eligible for grant funding in 2013. Grants funded new, discrete projects that could be implemented and developed over a 12-month period of time, starting in January 2013. Several CHCs were also awarded short-term, no-cost extensions.

In administering the 2013 grants, PCH used these guiding principles:

• Projects would enhance CHC readiness for new initiatives and funding arrangements (such as the Affordable Care Act, state payment reform and/or global payment arrangements).

• Projects would include (1) defined and measurable goals, (2) demonstrated ability to enhance readiness for the above reforms, and (3) plans for sustainability beyond the funding period.

Funded projects were awarded in the range of $20,000 to $150,000 (based on NHP membership), which could be used for either capital or operating expenses.

Targeted Grant Areas

In 2013, PCH awarded one-year grants to CHCs for projects focused on one or two of the following four areas:

• IT Reporting Capacity (13 grants)

• Meaningful Use Implementation (17 grants)

• Coding Training (7 grants)

• Training and Capacity Building for Performance Improvement (12 grants)

Reporting and Accountability

This report describes the Partnership for Community Health’s 2013 round of grant-funded projects implemented at CHCs across the state. The outcomes included are reported by the community health centers, made possible through grant funding from the Partnership for Community Health.

The Partnership for Community Health: 2013 Funding Eligibility and Target Areas

6 Executive Summary

IT Reporting Capacity Grant Recipients

› Brockton Neighborhood Health Center

› Community Health Center of Cape Cod

› Community Health Connections Family Health Centers

› Duffy Health Center

› East Boston Neighborhood Health Center

› Edward M. Kennedy Community Health Center

› Family Health of Worcester

› Holyoke Health Center

› Joseph M. Smith Community Health Center

› Lowell Community Health Center

› North Shore Community Health, Inc.

› South End Community Health Center

› Upham’s Corner Health Center

IT Reporting Capacity: Technology for Better Outcomes















7IT Reporting Capacity: Technology for Better Outcomes

In today’s healthcare environment, it’s critical that health

centers have the reporting tools and resources to improve

patient experience, the health of its populations, and

the cost of care. Thirteen of the PCH grants, totaling

$1,355,000, supported projects targeted at improving

CHCs’ IT Reporting Capacity. These grants provided

significant, one-time support for health centers to build

information technology infrastructure and reporting tools.

The goal of these tools is to help health centers monitor

performance in clinical outcomes, and track and target

specific populations. This will help CHCs make better

business decisions and medical records investments

that can ultimately enhance service delivery to patients.

PCH grants in the IT Reporting Capacity area fell into

three areas: 1) improving reporting infrastructure to support

Patient-Centered Medical Home and Meaningful Use;

2) developing reporting tools for better business decisions

and population health management; and 3) implementing

or upgrading EMRs to increase reporting capacity.

Grants Awarded

Further details about each of the awarded grants and CHC-reported outcomes summarized on the following pages can be found in the appendix.


8 IT Reporting Capacity: Technology for Better Outcomes

Grant Area: Improving reporting infrastructure to support Patient-Centered Medical Home and Meaningful Use

Grants in this area of IT Reporting helped CHCs make improvements so they can monitor their performance related to Patient-Centered Medical Home and Meaningful Use. Through these awards, health centers have begun to receive Patient-Centered Medical Home distinctions and Meaningful Use payments, and report improvement of key patient indicators.

› Community Health Center of Cape Cod Grant amount: $75,000

Goal: Improve IT reporting for a Patient-Centered Medical Home and implement a patient portal available through its EMR.

Results: The health center attained Patient-Centered Medical Home recognition through NCQA, and created a ‘super medical assistant’ position with a comprehensive training program to support its medical homes. The health center has begun to see quality improvements in several areas, including immunization compliance across all age groups, and mammography screening has increased from 48 to 78 percent during the grant period.

› East Boston Neighborhood Health Center (see spotlight on page 12)

Grant amount: $150,000

Goal: Improve its capacity to report on payment reform outcomes.

Results: As part its medical home efforts, the health center increased its two-day hospital discharge follow-up capture rate from 23 to 71 percent. Documented asthma action plans for persistent asthmatics increased from 73 to 87 percent. The health center received Level 3 Patient-Centered Medical Home recognition from NCQA as a result. The health center also reported positive patient response to increased outreach at hospital discharge, with improved transition and follow-up care. Patients report feeling more empowered to manage their asthma.

Description of Funding



› Edward M. Kennedy Health Center Grant amount: $125,000

Goal: Develop a risk management group to improve reporting.

Results: The health center achieved Patient-Centered Medical Home recognition, and has begun to receive Meaningful Use incentive payments, as a result of the grant.

› Family Health of Worcester Grant amount: $125,000

Goal: Restructure medical records, information technology and data analysis to support both Meaningful Use and Patient-Centered Medical Home targets; and create mechanisms to monitor key patient-care indicators.

Results: The health center exceeded its goal and attained Level 2 Patient-Centered Medical Home attestation during the grant period, and is now working towards Level 3.

› South End Community Health Center Grant amount: $100,000

Goal: To add and implement resources to help achieve quality standards.

Results: The health center reached Meaningful Use Stage 1 for all of its providers, and created a permanent Director of Quality position – laying the groundwork for a culture of quality improvement.

› Community Health Connections Family Health Centers Grant amount: $75,000

Goal: Improve diagnosis and procedure coding in its NextGen EMR, and provide training for staff on coding and reporting in its NextGen database.

Results: The health center trained staff in either coding or reporting, and diagnosis coding and NextGen reporting were improved.

Grant Area: Developing reporting tools for better business decisions and population health management

IT Reporting Capacity grants are enabling health centers to bring together disparate data systems to create easy-to-use tools. These powerful tools help illustrate real-time data that health centers can use to directly inform operations and population health management. With this effort, health centers report that they have improved patient response rates, created better tracking for referrals to specialty hospitals and improved their ability to analyze the quality of care they deliver.



› Duffy Health Center Grant amount: $30,000

Goal: Enhance its outcomes reporting across behavioral health and medical records, to improve the integration of care.

Results: The health center has improved reporting capabilities for integrated care, includ-ing implementing automated patient data entry and outcomes reporting; and data is now captured to Medicare standards. The health center also implemented a patient portal, and is identifying ways to further engage its homeless patients with the technology.

› Holyoke Health Center Grant amount: $75,000

Goal: Develop Azara DRVS data-reporting systems, an analytics and reporting platform for CHCs to create custom reports and compare outcomes with similar health centers, to increase the quality of care.

Results: For both health centers, the PCH grant has led to greater data analysis in clinical programming and better positioned the health centers for upcoming payment reforms. This change in systems has increased revenue, and 93 percent of billings are now collected.

› Joseph M. Smith Community Health Center Grant amount: $125,000

Goal: Create a sustainable system to track referrals made to Children’s Hospital.

Results: As a result of the grant, the health center has increased the percentage of returned specialist notes by 60 percent.

› Lowell Community Health Center Grant amount: $150,000

Goal: Implement a complex, sustainable reporting and dashboard solution to present data to providers and staff on operational statistics, patient experience metrics and clinical outcomes.

Results: As a result of the new reporting functions, the health center was able to allocate resources to those areas; the answer rate has improved from 35 percent to 65 percent, with a target of 90 percent. Lowell estimates that the new tools will support the health cen-ter’s reporting needs for the next three to five years.


› Brockton Neighborhood Health Center Grant amount: $125,000

Goal: Implement an electronic dental record.

Results: Brockton’s dentists are meeting Meaningful Use standards, better coordinating care and better tracking patient completion of care plans.

› North Shore Community Health Grant amount: $100,000

Goal: Update the health center’s EMR to develop new workflows to create efficiencies for provider reporting.

Results: With this upgrade, the health center has implemented a Patient-Centered Medical Home management plan. Providers report that care plans and self-management work has helped patients to consistently take medications and focus their patient visits more toward goals.

› Upham’s Corner Health Center Grant amount: $100,000

Goal: To convert its EMR so the health center can better coordinate clinical information with its affiliate, Boston Medical Center (BMC).

Results: Health center’s EMR has been successfully converted and staff trained; they can now create custom reports to assess the quality of care.

Grant Area: Implementing or upgrading electronic medical records (EMRs) to increase reporting capacity

Electronic medical records are the linchpin for IT improvements like data decision-making, performance monitoring – and, ultimately, pay-ment reform. Grants in this sub-area helped health centers implement or upgrade their EMR systems, so they can increase their ability to create reports and lay the groundwork for alternative payments. As a result, health centers report that they are better tracking patient care and coordination, and laying the groundwork for Meaningful Use.


COMMUNITY HEALTH CENTER SPOTLIGHT IT Reporting Capacity: Technology for Better Outcomes

East Boston Neighborhood Health Center: Data Drives Quality Improvement

Many organizations struggle with how to best capture and report on “big data” in meaningful ways. Community health centers have limited resources to collect and interpret patient data, both to improve care and to implement health reform requirements. To do so typically requires significant infrastructure improvements. These challenges took center stage for East Boston Neighborhood Health Center (EBNHC) as the CHC worked to meet state payment reform criteria and transition to the Patient-Centered Medical Home model. With funding from the Partnership for Community Health (PCH), EBNHC was able to access the data more effectively to identify how data collection and reporting impacted patient health. EBNHC analyzed its current workflows and data capture methodologies in order to create stan-dards for data consistency. The outcomes had a significant impact for patients.

At EBNHC, childhood weight management has improved by six percent, diabetes self-manage-ment by 12 percent; asthma plan documentation has risen by 19 percent, and proper hospital follow-up documentation is up by a full 300 percent. Members of EBNHC care teams also report that patients are “amazed” to receive calls after hospital discharge.

Building on this success, the health center implemented a Clinical Quality Measures workgroup, creating a process to quickly develop and validate new measures in the future. A new Reporting Manager generates reports and collects data for the workgroup, which then interprets and com-municates the data to care team members who are positioned to make needed improvements.

The data quality improvement project is a logical next step in continuing the system improve-ments that the health center has already achieved on the way to Level 3 recognition by the National Committee for Quality Assurance (NCQA). The new PCH-supported processes have enabled EBNHC to leverage new data to continue to improve continuity of care for their patients.

Meaningful Use Implementation Grant Recipients

› Cambridge Health Alliance Health Centers

› Caring Health Center

› Codman Square Health Center

› Community Health Center of Franklin County

› Family HealthCare Center at SSTAR

› Fenway Community Health Center

› Greater New Bedford Community Health Center

› Greater Roslindale Medical & Dental Center

› Harvard Street Neighborhood Health Center

› HealthFirst Family Care Center

› Lynn Community Health Center

› Martha Eliot Health Center

› Mattapan Community Health Center

› MGH Community Health Associates

› Roxbury Comprehensive Community Health Center

› South Cove Community Health Center

› Springfield Health Services for the Homeless Health Center

Meaningful Use Implementation: Incentives for Better Care






15Meaningful Use Implementation: Incentives for Better Care

To help community health centers remain competitive

through payment reform and be eligible for incentives,

17 grants totaling $1,510,000 were focused on Meaningful

Use Implementation. Implementation is divided into three

graduating stages, with increasing responsibility for partici-

pation, and poses unique challenges for community

health centers.

These Meaningful Use Implementation grants provided

significant, one-time support for health centers to increase

capacity to “meaningfully use” data to improve patient

care. Support was directed toward CHC Meaningful Use

Implementation in four ways: 1) improving IT infrastructure

and security; 2) upgrading or implementing EMR systems;

3) increasing capacity to monitor Meaningful Use clinical

quality measures; and 4) establishing an online patient

portal for patients to communicate with providers.

Grants Awarded



16 Meaningful Use Implementation: Incentives for Better Care

Grant Area: Improving IT infrastructure and security

To implement Meaningful Use and use data to improve care, health centers must first have the proper IT infrastructure and security. Grants in this area provided necessary, one-time support to help CHCs lay the groundwork for Meaningful Use Implementation, across the three stages of participation. With these grants, health centers have developed the building blocks to meaning-fully use the data that has been entered into an effective, secure EMR.

› Family HealthCare Center at SSTAR Grant amount: $75,000

Goal: Implement a stable, virtual server.

Results: The health center can now upgrade its EMR to a version that includes a patient portal and meets Meaningful Use objectives.

› Fenway Community Health Center Grant amount: $50,000

Goal: Implement Meaningful Use compliant software and build the necessary infrastructure for electronic prescribing of controlled substances, expected to be a required objective for Meaningful Use in 2016.

Results: The new system aims to improve health outcomes by monitoring the use of controlled substances, checking for potentially harmful medical interactions, and preventing fraud and abuse. It will also reduce the time required to process prescriptions for controlled substances.

› Lynn Community Health Center Grant amount: $150,000

Goal: Improve health center’s IT infrastructure by securing communications channels, back-up and disaster recovery protocols.

Results: The project enabled 52 of the health center’s 53 providers to successfully meet Meaningful Use, Stage 1 objectives.



› Roxbury Comprehensive Community Health Center Grant amount: $25,000

Goal: Develop Meaningful Use forms and provide training for IT staff.

The health center closed during the grant period and therefore did not complete the project.

› Springfield Health Services for the Homeless Health Center Grant amount: $30,000

Goal: Move its EMR to an externally managed service from the city-based service.

Results: The health center moved its EMR, which has enabled it to provide more seamless services for patients.

› Caring Health Center (see spotlight on page 22)


Goal: Implement a new EMR, a major component of the health center’s effort to become a Patient-Centered Medical Home and a central focus for Meaningful Use.

Results: With the new EMR, the health center has achieved Meaningful Use Stage 1, and has begun receiving the associated incentive payments.

› Codman Square Health Center Grant amount: $125,000

Goal: Add Meaningful Use objectives to its EMR forms.

Results: The health center can now monitor objectives on a weekly basis, and can now achieve Meaningful Use attestation. The health center also developed EMR forms for its Patient-Centered Medical Home efforts, which will allow it to maintain its Level 3 recognition.

Grant Area: Upgrading or implementing EMR systemsOnce the proper IT infrastructure and security is in place, health centers can focus on meeting Meaningful Use objectives with their EMRs. Grants in this area funded projects to upgrade or implement an EMR to support Meaningful Use goals. With this funding, the health centers have moved their EMRs forward toward better coordinated care while complying with Meaningful Use objectives. Some health centers report that the use of technology has helped enhance patient-provider communication and education.




› Greater Roslindale Medical and Dental Center


Goal: Move its dental department from paper to electronic charting.

Results: Health center’s EMR platform is now certified for Meaningful Use, for both medical and dental. The move to electronic charting has enhanced both the patient and provider experience.

› Harvard Street Neighborhood Health Center Grant amount: $75,000

Goal: Successfully implement a Meaningful Use certified and ICD-10 compliant EMR.

Results: The EMR has been implemented and the health center has input the necessary data to begin collecting and monitoring Meaningful Use objectives. The EMR also includes a patient portal.

› HealthFirst Family Care Center Grant amount: $75,000

Goal: Implement an EMR for medical and dental services.

Results: The EMR was implemented, and trainings for staff have allowed the health center to meet Meaningful Use measures and increase the quality of care. The new digital technol-ogy has lessened patient wait times from twenty to five minutes for dental radiographs, and increased patient-provider communication. Discussing treatment plans with patients and educating them about oral health has become easier, as patients are able to see enhanced images through digital technology.


› Community Health Center of Franklin County Grant amount: $30,000

Goal: Develop reports and dashboards to monitor clinical quality measures for Meaningful Use.

Results: The health center has experienced an increase in patient satisfaction, and the grant has enabled providers to select clinical measures for Meaningful Use Stage 2. Patients have begun to benefit from the health center’s improved ability to demonstrate projected health outcomes through dashboards and graphs, made available through Meaningful Use clinical quality measures. Health center providers are able to graphically demonstrate troubling health trends to their patients, which can help them to successfully encourage patients to change behavior.

› Martha Eliot Health Center Grant amount: $125,000

Goal: Improve quality-reporting capabilities related to Meaningful Use.

Results: The health center adopted a set of measures to track process and outcomes over time, and is engaging care teams to design and test quality and outreach improvements, and monitor the impact on care. Over the grant period, the health center increased well-child visits by 93 percent, exceeding its goal of 75 percent. The funding afforded the health center the time and resources to develop a quality improvement program, and begin to train staff on how to implement interventions to improve operations and care. The successes led to a new hospital-funded quality improvement position at the health center.

Grant Area: Increasing capacity to monitor Meaningful Use clinical quality measures

Grants in this sub-area funded projects to increase health center capacity, and identify and monitor Meaningful Use clinical quality measures. With the proper IT infrastructure and EMRs in place, health centers can then develop internal reports and new workflows that meet Meaningful Use. These health centers moved their Meaningful Use status forward while creating new ways to analyze clinical data and improve coordination.


› Mattapan Community Health Center Grant amount: $50,000

Goal: To engage a consultant to assess the health center’s Meaningful Use readiness, adjust workflows, and develop the necessary reports to monitor Meaningful Use clinical quality measures. The health center also used grant funding to connect to Azara DRVS.

Results: The health center is better positioned to meet Meaningful Use objectives.

› South Cove Community Health Center Grant amount: $125,000

Goal: Expand its medical home model to two additional sites, and prepare for Meaningful Use.

Results: The health center received full NCQA Level 3 Patient-Centered Medical Home accreditation for all three of its sites, and providers were approved for Meaningful Use Stage 1. The grant allowed the health center to reorganize policies to standardize data entry in the EMR for Meaningful Use, to ensure that patients receive the highest quality of care. The health center added two pharmacists and two pharmacy techs to its team, and ensured that patients given medications receive culturally competent explanations from doctors, nurses and at the pharmacy. By becoming a Level 3 Medical Home at all three sites and certified as meaningful users of its EMR, the health center is better positioned to bring high-quality, low-cost care to a vulnerable population.


› Cambridge Health Alliance Health Centers Grant amount: $125,000

Goal: Increase patient engagement for four of its sites with its patient portal.

Results: The health center sought feedback from patients, then created marketing and education brochures, videos and posters to convey information about the patient portal and how to use it. The health center achieved a combined increase of 52 percent in patient portal usage over the previous year. The sites are now in a better position to reach Meaningful Use Stage 2 objectives as portal usage increases.

› Greater New Bedford Community Health Center Grant amount: $125,000

Goal: Upgrade to a Meaningful Use-compliant EMR and implement a patient portal to provide patients with an alternative option to engage in care.

Results: The health center was able to web-enable 1,764 patients for the new patient portal, with 561 successful logins and 754 individual labs reviewed.

› MGH Community Health Associates Grant amount: $150,000

Goal: Implement the Patient Gateway and Health Education Project, introducing iPads and kiosk computers into each health center practice to improve access to the Patient Gateway, the health centers’ patient portal.

Results: The health centers developed multilingual education materials on wellness and chronic disease management. The health centers were able to increase patient enrollment in the Patient Gateway by 27 percent, exceeding its goal of 15 percent. The health centers also developed and implemented a low-literacy booklet with instructions on accessing the portal.

Grant Area: Establishing an online patient portal for patients to communicate with providers

An EMR with proper infrastructure, security and reporting capabilities is the foundation for Meaningful Use – but a patient portal is also essential (and required by Meaningful Use Stage 2) for health centers to engage and educate patients. These grants were awarded to help CHCs implement portals and educate patients on the benefits of online communication tools. As a result, centers report increasing enrollment in patient portals, which can improve patient-provider communication.


COMMUNITY HEALTH CENTER SPOTLIGHT Meaningful Use Implementation: Incentives for Better Care

Caring Health Center: Grant-funded EMR Empowers Better Patient Care

Caring Health Center in Springfield, Massachusetts had lofty goals for its electronic medical record system (EMR). However, the community health center was considered undersized for an implementation by Epic, a leading EMR provider.

With Partnership for Community Health (PCH) support, Caring Health Center partnered with an Oregon-based health information network (OCHIN) to present an economy of scale. The innova-tive partnership, which included OCHIN’s extensive system of health centers, was essential to the successful implementation of the Epic EMR system at Caring Health. In addition, PCH funding covered Epic EMR implementation costs, freeing up Caring Health to apply its own funds toward operating costs to launch the new EMR system.

The PCH grant also enabled Caring Health Center to provide new computers for the health center to use in exam rooms – extending the usefulness of EMR to the point of care. Using the PCH-funded electronic medical record system, Caring Health Center is now poised to receive Meaningful Use incentives. The health center reports that efficiency has improved – with visits and revenue on the rise.

Enhanced reporting and tracking capabilities powered by the new EMR system is paying divi-dends for patient care. The diabetes care team uses the Epic system to track vital indicators of patient success – from labs to routine foot exams – with a few mouse clicks. As a result, the health center reports that patients are more frequently and predictably following through on care and specialist referrals. In addition, e-prescribing has made it easier to ensure that pre-scriptions arrive at patients’ pharmacies faster, and medication lists are easily reconciled during routine visits.

By increasing its footprint through a PCH grant, Caring Health Center has acquired an EMR that helps the health center deliver more effective chronic disease care to patients in need.

Coding Training Grant Recipients

› Baystate Medical Center Health Centers

› Boston Health Care for the Homeless Program

› Community Health Programs

› Dimock Community Health Center

› Dorchester House Multi-Service Center

› Greater Lawrence Family Health Center

› South Boston Community Health Center

Coding Training: Improving Patient Records & Reimbursement

25Coding Training: Improving Patient Records & Reimbursement

As health care moves from a fee-for-service environment to

global payment and risk-share arrangements, CHCs must

have the infrastructure to ensure patients in vulnerable

communities receive the right care, at the right time, in

the right place. To this end, it’s critical that CHCs properly

document and code care to align with quality and payment

standards. Seven projects, with a grant amount of $495,000,

were focused on coding training.

Grants Awarded



26 Coding Training: Improving Patient Records & Reimbursement

Coding Training grants helped centers conduct chart audits, to identify opportunities to increase patient record accuracy and receive appropriate reimbursement for services. Grants were also used to invest in human resources – including training for staff, engaging expert consultants and bringing on additional staff – with a focus on coding accuracy and quality improvement. As a result, CHCs have identified gaps in coding and billing, and report that they have improved accuracy, compliance and patient satisfaction.

› Baystate Medical Center Health Centers Grant amount: $20,000

Goal: A train-the-trainer boot camp for its staff on the upcoming ICD-10 coding methodology.

Results: The health center’s increased capacity in coding will positively impact revenue.

› Boston Health Care for the Homeless Program Grant amount: $30,000

Goal: A coding course, trainings and an outside consultant to conduct a chart audit.

Results: The health center Coding Specialist became a Certified Professional Coder, which is invaluable to the organization, as it will now have capacity for internal audits – which will save health center resources in the long term.

› Community Health Programs Grant amount: $20,000

Goal: To improve coding, documentation and billing at five health centers, which has helped increase appropriate reimbursement and improve the accuracy of patient records.

Results: The project has significantly improved OB/GYN coding and documentation. The grant helped CHP to capture more than $5,000 in additional revenue each month for tasks that were done but had not been properly documented. As a result, OB/GYN, which had been losing money each year since 2009, met its budgeted goal just halfway through the year.


27Coding Training: Improving Patient Records & Reimbursement

› Dimock Community Health Center (see spotlight on page 28)


Goal: To support the development of a Quality Improvement/Compliance Officer position at the health center, and conduct a coding audit with a focus on hypertension and asthma.

Results: As a result of this effort, the health center surpassed its hypertension blood pressure control rate of 60 percent. It also surpassed its goal of 65 percent of asthma patients on controller medications, reaching 90 percent. Adult medicine went from 65 to 88 percent in ‘coding matches,’ and pediatrics went from 62 to 76 percent. Support from PCH will allow the health center to determine patterns in coding gaps, identify training needs and track coding compliance over time. The improved coding compliance will help to refine registry outreach, improving accuracy in billing and in-risk scores.

› Dorchester House Multi-Service Center Grant amount: $100,000

Goal: Engage a consultant to advise, plan and conduct its coding improvement project.

Results: The consultant analyzed practices, and from their assessment, the health center redesigned workflows and provided additional staff training. The health center also hired a full-time coding analyst to gauge success and develop ongoing performance improvement. An unexpected finding from the audit was that claim denials often occurred at patient reg-istration, due to lapsed or changed insurance. To respond to the issue, the health center established a central registration and call center for staff to confirm billing and insurance information 2-3 days before a visit, and connect patients to insurance enrollment services. Now that the project is complete, wait time is typically 30-60 seconds at check-in rather than 10 minutes, improving overall patient satisfaction. As a result of the project, the health center has increased its collection rates and decreased turnaround time for reimbursement.

› Greater Lawrence Family Health Center Grant amount: $150,000

Goal: Conduct a risk adjustment audit, which helped the health center to identify areas for improvement.

Results: The health center has identified several areas to focus on to increase the accuracy of its coding documentation, such as diabetes with a manifestation, chronic kidney disease and depression. The health center has also worked to modify its staff trainings to further support accurate coding.

› South Boston Community Health Center Grant amount: $100,000

Goal: Training on risk-adjusted coding for its providers.

Results: Through the project, the health center delivered training to providers while also working on continuity of provider teams for patients. The health center reports increased patient satisfaction due to continuity of seeing the same primary care team at each visit.



28 Coding Training: Improving Patient Records & Reimbursement

Dimock Community Health Center has a legacy of providing high-quality health care in Roxbury, Massachusetts. As the community’s health care needs continued to evolve, Dimock was chal-lenged with finding new ways to manage a high volume of patients with pediatric asthma.

With a Partnership for Community Health grant, Dimock expanded its use of its EMR system from recording office visits to providing clinical decision support. Outcomes from this project include: standardized clinical protocols for hypertension and pediatric asthma; improved work-flows to address population health in real time; and enhanced patient outreach, including nurse visits to the highest-risk patients. In addition, registry reports of patients with asthma are now run from the EMR and sorted by severity.

The health center has turned its focus to the delivery of care for specific patient populations, and more tailored approaches for those who need additional support. Disease severity of the patient population is more accurately incorporated into Dimock’s risk adjustment and chronic disease measures. For example, factors like hypertension control and pediatric asthma controller medications are displayed directly on the EMR dashboard.

Benefits provided by the PCH grant can now be extended to other conditions for patient populations impacted by a range of chronic diseases. The result: more coordinated care for health center’s chronically ill patients.

COMMUNITY HEALTH CENTER SPOTLIGHT Coding Training: Improving Patient Records & Reimbursement

Dimock Community Health Center: Unlocking the Potential of the EMR

Training and Capacity Building for Performance Improvement Grant Recipients

› Bowdoin Street Health Center

› Brookside Community Health Center

› Harbor Health Services – Geiger Gibson

Community Health Center

› Harbor Health Services – Harbor Community

Health Center –Hyannis

› Harbor Health Services – Neponset Health Center

› Hilltown Community Health Center

› Island Health Care

› Manet Community Health Center

› North End Waterfront Health

› Outer Cape Health Services

› Southern Jamaica Plain Health Center

› Whittier Street Health Center

Training and Capacity Building for Performance Improvement

31Training and Capacity Building for Performance Improvement

Training and Capacity Building translates to performance

improvement, so CHCs can continue to provide low-cost,

high-quality care. PCH funding went to 12 projects in the

Training and Capacity Building for Performance Improvement

targeted grant area, totaling $865,000 in funding for

community health centers in Massachusetts.

Grants in this area provided critical seed funding for strategic

performance improvement projects. These projects are aimed

at keeping community health centers at the cutting edge of

health care in Massachusetts, while increasing patient satis-

faction and curtailing costs. Three sub-areas within Training

and Capacity Building were funded: 1) quality improvement

training 2) workflow redesign and 3) increased capacity for

population health management.

Grants Awarded



32 Training and Capacity Building for Performance Improvement

Grant Area: Quality improvement training

For quality improvements to succeed in a health care setting, problems must be identified and well analyzed, and solutions directed by those responsible for implementing change. These grants supported cross-functional teams in their efforts to solve problems, eliminate waste – and, ultimately, create lasting improvements in operations. As a result, health centers have reported improvements – from better audit scores to reduced wait times for patients.

› Brookside Community Health Center Grant amount: $125,000

Goal: Engage a quality improvement trainer to develop its internal capacity on LEAN and quality improvement methods and explore potential quality improvement projects for the health center, with a focus on primary care.

Results: The health center also hired a consultant to conduct record reviews and provide trainings on the most current level of coding orientation. As a result, 11 of the health center’s 13 clinicians scored a 90 percent or better in the audit (the remaining 2 clinicians scored 80 percent).

› Hilltown Community Health Centers Grant amount: $30,000

Goal: LEAN training

Results: The training has improved service to patients by helping to create more robust quality improvement policies and workflows. The cross-departmental LEAN team identified wait time as a point of significant patient dissatisfaction and took steps to reduce it. Their interventions, including using wait time for patient education, resulted in increased patient satisfaction.

› Outer Cape Health Services (see spotlight on page 36)


Goal: Provide LEAN training for center staff and identify a patient-flow improvement project to work through the quality improvement process.

Results: As a result of the project, the health center has reduced patient wait time, from an all-time high of three hours, to 30 minutes for walk-ins. The health center achieved these outcomes by creatively triaging patients with the help of the new process and tools, includ-ing a walkie-talkie for the front desk to more quickly and efficiently locate its triage nurse.




› Southern Jamaica Plain Health Center Grant amount: $100,000

Goal: Hire a Training Specialist to provide staff training on a range of topics including LEAN, Customer Service for Practice Assistants, Team Building, Motivational Interviewing and specialized MI training for doctors.

Results: In addition to hiring the specialist, staff was trained in Excel skills as well as the social determinants of health. The culture of the health center has changed, with frontline staff empowered and trained to participate in improvement processes. The health center will complete its Patient-Centered Medical Home submission with NCQA in October 2014.

› Harbor Health Services – Geiger Gibson Community Health Center Grant amount: $50,000

Goal: Build and develop the headquarters for an agency-wide call center to provide informa-tion and to connect patients with providers.

Results: The health center achieved a 95 percent answer rate and reduced call complaints from 50 to 5 percent. The health center also improved connectivity between patients and providers, core to the Patient-Centered Medical Home practice transformation.

› Harbor Health Services–Harbor Community Health Center–Hyannis


Goal: Implement a training program similar to the Neponset health center (see page 34).

Results: The funding increased provider efficiency and helped the health center to prepare for Primary Care Reform and global payments, and advance its work towards the Patient- Centered Medical Home model.

Grant Area: Workflow redesignThis set of grants helped CHCs increase efficiency in their operations, specifically in their team workflow, while advancing care for community health center patients. As a result, centers report improved preparation for Patient-Centered Medical Home transitions, and better response to patient inquiries.



› Harbor Health Services–Neponset Health Center Grant amount: $100,000

Goal: Implement a training program for nurses and clinical support staff to function as a multidisciplinary Patient-Centered Medical Home.

Results: The funding offered an important opportunity for the health center to address its Patient-Centered Medical home roadblocks and goals for moving forward.

› Bowdoin Street Health Center Grant amount: $75,000

Goal: Improve and extend the benefits of the Patient-Centered Medical Home to more patients by adding a full-time nurse to focus on the standardization of assessments, care planning, action plans and individualized interventions.

Results: The health center increased access to care management services from 176 patients to 319.

› Island Health Care Grant amount: $30,000

Goal: To train staff and phase-in the Chronic Care Model (CCM), which includes collabora-tive goal setting and problem-solving, where the patient is informed and plays an active role.

Results: The health center incorporated four of the six CCM components into its daily flow. Leveraging concurrent programming, the health center was able to incorporate health coaching, patient chronic disease management and nutrition classes, producing a “one-stop shopping” environment for chronic disease patients. This increases the rate of successful referrals to self-management.

Grant Area: Increased capacity for population health management

With these grants, health centers have increased their capacity to manage population health by adding new staff and engaging consultants with content-area expertise. The projects in this grant area also helped increase data reporting capabilities, to identify patients and high-risk populations that could benefit from care management. As a result, some centers report that access to care management has increased for patients, and that compliance measures have improved in multiple categories of care.


› Manet Community Health Center Grant amount: $125,000

Goal: Hire a nurse care manager at each of its five sites.

Results: The health center’s largest site, North Quincy, was awarded Level 2 Patient-Centered Medical Home and the health center is working towards Level 3 at all of its sites. The health center also created new dashboards in its EMR, which are provided to care managers to conduct outreach.

› North End Waterfront Health Grant amount: $50,000

Goal: Hire an RN Quality Care Manager and develop a pre-screen tool to ensure screening is an integral part of a visit and not provider-dependent.

Results: As a result of the project, the health center has improved its PAP smear compli-ance from 48 to 98 percent, and improved colonoscopy protocol compliance from 38 to 66 percent, for female patients.

› Whittier Street Health Center Grant amount: $100,000

Goal: Increase capacity to provide case management services to high-risk patients by adding both an RN and a case manager.

Results: The health center developed a high-risk patient panel, provided patients with case management, and continuously monitored their health outcomes. Through this effort, the health center had increased the percentage of patients with annual physicals and care plans from 41 to 62 percent, and clinical summaries are now printed for 83 percent of patients – up from 73 percent.


COMMUNITY HEALTH CENTER SPOTLIGHT Training and Capacity Building for Performance Improvement

Outer Cape Health Services: LEAN Approaches Lower Patient Wait Times

For Outer Cape Health Services, LEAN – the management approach that emphasizes customer value and minimal waste – had potential to remove a barrier to providing quality care. Walk-ins at the health center impacted service, created long wait times for patients, and limited the total number of patients the health center could see in a given day.

With support from a Partnership for Community Health (PCH) grant, Outer Cape participated in six months of LEAN training, hosted by the Massachusetts League of Community Health Centers. Initially, the health center’s staff hypothesized that a new staffing model was the only way to solve the patient wait time caused by walk-in visits. Through LEAN training, which provided tools to help staff examine the problem in a different way, the health center discovered that a change in workflow could resolve service issues. The new revelation enabled staff to reallocate resources by implementing same-day and walk-in blocks for patients without an appointment.

As a result of the reorganization, the health center has reported improved efficiency across its sites. At the Provincetown, Massachusetts location, the number of appointments disrupted by a walk-in was cut from 15 to just eight. Patients experienced a reduction in wait time – from an average of 3.2 hours, to just 30 minutes. With support from PCH, Outer Cape Health Services significantly improved its patient experience across locations.

38 Looking to the Future

Looking to the Future

FinancialStability

Goal: To fund thetransformation

ClinicalExcellence

Goal: To advanceclinical excellence

Workforce/LeadershipGoal: To recruit& retain a highlycapable workforce

Strategic PlanningGoal: To be

proactive ratherthan reactive

Growth/Market ShareGoal: To represent& serve thecommunity

Excellence& Innovation

Goal: To be thepractice of choice

Operational innovationService excellence

High Performing

CHCs

Partnership for Community HealthStrategic Foundation 2014-2016

In 2013, Partnership for Community Health grants provided $4.225 million in meaningful support to all 491 CHC organizational members of the League. These awards helped health centers advance their Patient-Centered Medical Home efforts, meet state and federal health reform requirements, and make other critical operational improvements.

The efficiencies and quality improvements created through these Partnership for Community Health 2013 grants are arming centers with new resources and reporting tools so they can improve their patient experience. Ultimately, the goal is to enhance the health of communities, and lower the cost of care. With this support, health centers can continue to remain at the forefront of care in Massachusetts while making the transition to new payment and quality standards as part of broad reform efforts.

The support provided through the Partnership in 2013 laid the groundwork for CHCs to build further infrastructure and make even greater enhancements, so they can keep pace with today’s changing health care environment.

Next Steps: Excellence and Innovation Program

Both public and private resources to support high-performing health centers in their leadership development and clinical excellence goals are scarce. The PCH Grant-Making Board and CHC Advisory Board developed a strategic foundation and decided to focus funding on Excellence and Innovation for 2014-2016.

In 2014, the Partnership awarded $6 million in funding for an Excellence and Innovation grant round. The goal of this funding is to provide meaningful support for new CHC projects that will enhance quality, service, efficiencies and outcomes at Massachusetts’ health centers. PCH Excellence and Innovation 2014 grants

39Looking to the Future

will target two-year projects with a specific focus in one of the following four areas: data and decision support, operational improvement, shared services, and engagement and communication.

The following key principles will guide the Partnership in administering this grant program:

• Although the Excellence and Innovation round of grants will be competitive, funding will go to relevant projects that will benefit as many health centers as possible.

• All CHC Organizational Members of the League are eligible to submit an application for grant funding.

• PCH will fund both individual ($300,000 – $600,000) and multi-organizational grants (up to $1 million).

• Multi-organization grants are focused on encouraging collaboration among health centers.

The Excellence and Innovation grants will support patient use of interactive health technology, and develop shared services and data capacity across multiple health centers – all with the broad aim of lowering costs while improving patient care.

With positive results from the 2013 grant round, the Partnership has shown that targeted grant making can provide meaningful, sustainable support that helps to enhance care quality at community health centers. Any future rounds of PCH grant funding, beginning with the Excellence and Innovation program, will build on these successes. The PCH will continue to support commu-nity health centers in their efforts to remain at the forefront of health care in Massachusetts, by providing low-cost, high-quality care.

1 One CHC closed during the grant period; and therefore, did not complete their project.

Appendix: 2013 PCH Grants Full Results by Target Area

42 Appendix: 2013 PCH Grants Full Results by Target Area

TABLE 1

Partnership for Community Health 2013 Outcomes - IT Reporting Capacity

Organization Name Amount Grant Activities Results

Brockton Neighborhood Health Center (BNHC), Brockton

$125,000 • Implemented a dental EMR.

• Trained 100% of staff on the new EMR.

BNHC implemented a dental EMR which has enabled its dentists to meet Meaningful Use objectives and to better track patient completion of dental care plans. Dentists and medical staff now have easy access to both medical and dental records, which is particularly important for coordinating care for patients with complex medical needs such as HIV, Diabetes, and those on Coumadin.

Community Health Center of Cape Cod,Bourne, Falmouth, Mashpee

$75,000 • Implemented Patient-Centered Medical Home through improved capacity for IT reporting and performance improvement activities.

• Developed and implemented the patient portal available through its EMR.

Cape Cod attained Patient-Centered Medical Home recognition through NCQA. The health center also improved reporting capacity and created a ‘super medical assistant’ position with a comprehensive training program. Quality improvement expectations within a panel management framework were re-evaluated and procedures and tools were established for ongoing quality monitoring and reporting. As a result, the health center has seen quality improvements in several areas including immunization compliance across all age groups and mammography screening increased from 48 to 78 percent during the grant period.

Community Health Connections Family Health Centers (CHC), Fitchburg, Leominster

$75,000 • Hired a NextGen reporting consultant to provide training, review reports, and assist with new report development.

• Hired certified coding consultant to train providers and conduct chart audits.

CHC trained staff in either coding or reporting as result of this project. Both diagnosis coding and NextGen reporting were improved as a result of the grant.

Duffy Health Center, Hyannis $30,000 • Improved IT reporting for integrated care (BH/Medical).

• Automated entry of BH patient data.

• Increased BH outcomes reporting.

• Implemented a patient portal.

Duffy has improved reporting capabilities for integrated care with BH, and medical and data is now captured to Medicare standards. The health center implemented the patient portal and is identifying ways to further engage its homeless patients in using the technology.

East Boston Neighborhood Health Center (EBNHC), Boston

$150,000 • Built infrastructure and prepared for state payment reform and the Patient-Centered Medical Home model.

• Improved IT reporting capacity to monitor performance measures foundational to payment reform and alternative payment structures and the Patient-Centered Medical Home model.

• Hired a full-time IS Reporting Manager.

EBNHC improved capacity to monitor performance measures foundational to payment reform and the Patient-Centered Medical Home clinical model. During the grant period, the health center was able to increase its two-day hospital discharge follow-up capture rate from 23 to 71 percent. The health center was also able to increase its documented asthma action plans for persistent asthmatics from 73 to 87 percent. Through this work, EBNHC was able to achieve Level 3 Patient-Centered Medical Home recognition through NCQA.

Edward M. Kennedy Community Health Center (EMK), Framingham, Worcester

$125,000 • Developed a risk management and quality improvement department.

• Worked with IT and newly formed risk management group to improve reporting.

• Connected to Azara DRVS.

EMK achieved Patient-Centered Medical Home recognition, and began receiving Meaningful Use Stage 1 and Stage 2 compliance payments. The health center also used grant funding to connect to Azara DRVS, enabling the health center to benchmark its outcomes against other health centers. EMK also worked to improve reporting capabilities on risk scores which will improve financial outcomes.

Family Health of Worcester, Worcester

$125,000 • Implemented dental EMR.

• Hired consultant to develop templates and registries.

• Hired CIO.

• Developed reporting mechanisms to monitor performance.

Family Health restructured its medical records, IT, and data analysis functions to support Meaningful Use objectives and Patient-Centered Medical Home goals, and created internal mechanisms for monitoring key performance indicators. The health center exceeded its minimum goal of attaining Level 1 Patient-Centered Medical Home and attained Level 2 in fall 2013. The health center is now working towards Level 3 recognition.

Holyoke Health Center, Chicopee, Holyoke

$75,000 • Developed Azara DRVS data reporting and visualization system.

• Received technical assistance to address billing issues and reengineer financial systems.

Holyoke enhanced system configurations and developed Azara DRVS data reporting systems, which have led to greater data for analysis in clinical programming and has better positioned the health center to analyze upcoming payment reforms. The health center has implemented improvements that lead to enhanced revenue collection. This change in system has increased revenue and 93 percent of billings are now collected.

Joseph M. Smith Community Health Center (JMSCHC), Boston, Waltham

$125,000 • Enhanced processes for referral tracking and follow-up.

• Purchased a new Storage Area Network (SAN) for computer network to increase efficiencies and to successfully implement additional technologies to support quality improvement initiatives.

JMSCHC created a sustainable system for tracking referrals made to Children’s Hospital. At the beginning of the project, approximately 25 percent of specialist notes were returned. As a result of the grant, 80-90 percent of notes are returned and average time for receipt has improved from 52 to 17 days. JMSCHC built and piloted a high-functioning, small-scale model for tracking referrals, which it plans to bring to scale at its largest site with minimal disruption.

Lowell Community Health Center,Lowell

$150,000 • Implemented a reporting and dashboard solution to make better business and patient population management decisions.

• Created more efficient reporting processes.

• Prepared to address future reporting requirements.

• Trained staff on report generation.

Lowell implemented a complex reporting and dashboard solution which has enabled the health center to bring data together from disparate systems and to present relevant, actionable information to providers and staff who can directly improve operations and patient care. This project will have a long-lasting impact on patient care and experience.

North Shore Community Health, Inc. (NSCI), Gloucester, Peabody, Salem

$100,000 • Hired a Medical Director of Health Informatics.

• Expanded interfaces with hospitals and made improvements to current EMR reports and workflows.

NSCI updated its EMR successfully and developed new workflows to create efficiencies for provider reporting. The health center implemented a Patient-Centered Medical Home management plan and care plans to assist providers in more effectively tracking patient goals. The new reports and workflows meet several goals simultaneously: external requirements (such as Patient-Centered Medical Home reporting), tools to engage patients (integrated self-management plans), and care continuity (take-home care plans).

South End Community Health Center (SECHC), Boston

$100,000 • Hired a Meaningful Use consultant to help achieve standards.

• Hired a new Director of Quality.

• Implemented Azara DRVS.

SECHC achieved Meaningful Use Stage 1 for all providers and created a permanent Director of Quality position, laying the foundation for a culture of quality improvement at the health center. The health center also implemented AZARA DRVS, which enables it to benchmark outcomes against other health centers.

Upham’s Corner Health Center (UCHC),Boston

$100,000 • Converted EMR from Longitudinal Medical Record (LMR) to Centricity and received technical support.

• Implemented AZARA DRVS.

• Trained staff on Crystal Reports.

UCHC successfully converted its EMR system from LMR to GE Centricity. It implemented AZARA DRVS for quality reporting on clinical measures and provided two Crystal Reports trainings which allowed staff to create custom reports to assess quality of care. The new EMR has enabled the health center to coordinate clinical information with BMC and allows providers to e-prescribe.

43Appendix: 2013 PCH Grants Full Results by Target Area

TABLE 1

Partnership for Community Health 2013 Outcomes - IT Reporting Capacity


Brockton Neighborhood Health Center (BNHC), Brockton

$125,000 • Implemented a dental EMR.

• Trained 100% of staff on the new EMR.

BNHC implemented a dental EMR which has enabled its dentists to meet Meaningful Use objectives and to better track patient completion of dental care plans. Dentists and medical staff now have easy access to both medical and dental records, which is particularly important for coordinating care for patients with complex medical needs such as HIV, Diabetes, and those on Coumadin.

Community Health Center of Cape Cod,Bourne, Falmouth, Mashpee

$75,000 • Implemented Patient-Centered Medical Home through improved capacity for IT reporting and performance improvement activities.

• Developed and implemented the patient portal available through its EMR.

Cape Cod attained Patient-Centered Medical Home recognition through NCQA. The health center also improved reporting capacity and created a ‘super medical assistant’ position with a comprehensive training program. Quality improvement expectations within a panel management framework were re-evaluated and procedures and tools were established for ongoing quality monitoring and reporting. As a result, the health center has seen quality improvements in several areas including immunization compliance across all age groups and mammography screening increased from 48 to 78 percent during the grant period.

Community Health Connections Family Health Centers (CHC), Fitchburg, Leominster

$75,000 • Hired a NextGen reporting consultant to provide training, review reports, and assist with new report development.

• Hired certified coding consultant to train providers and conduct chart audits.

CHC trained staff in either coding or reporting as result of this project. Both diagnosis coding and NextGen reporting were improved as a result of the grant.

Duffy Health Center, Hyannis $30,000 • Improved IT reporting for integrated care (BH/Medical).

• Automated entry of BH patient data.

• Increased BH outcomes reporting.


Duffy has improved reporting capabilities for integrated care with BH, and medical and data is now captured to Medicare standards. The health center implemented the patient portal and is identifying ways to further engage its homeless patients in using the technology.

East Boston Neighborhood Health Center (EBNHC), Boston

$150,000 • Built infrastructure and prepared for state payment reform and the Patient-Centered Medical Home model.

• Improved IT reporting capacity to monitor performance measures foundational to payment reform and alternative payment structures and the Patient-Centered Medical Home model.

• Hired a full-time IS Reporting Manager.

EBNHC improved capacity to monitor performance measures foundational to payment reform and the Patient-Centered Medical Home clinical model. During the grant period, the health center was able to increase its two-day hospital discharge follow-up capture rate from 23 to 71 percent. The health center was also able to increase its documented asthma action plans for persistent asthmatics from 73 to 87 percent. Through this work, EBNHC was able to achieve Level 3 Patient-Centered Medical Home recognition through NCQA.

Edward M. Kennedy Community Health Center (EMK), Framingham, Worcester

$125,000 • Developed a risk management and quality improvement department.

• Worked with IT and newly formed risk management group to improve reporting.

• Connected to Azara DRVS.

EMK achieved Patient-Centered Medical Home recognition, and began receiving Meaningful Use Stage 1 and Stage 2 compliance payments. The health center also used grant funding to connect to Azara DRVS, enabling the health center to benchmark its outcomes against other health centers. EMK also worked to improve reporting capabilities on risk scores which will improve financial outcomes.

Family Health of Worcester, Worcester

$125,000 • Implemented dental EMR.

• Hired consultant to develop templates and registries.

• Hired CIO.

• Developed reporting mechanisms to monitor performance.

Family Health restructured its medical records, IT, and data analysis functions to support Meaningful Use objectives and Patient-Centered Medical Home goals, and created internal mechanisms for monitoring key performance indicators. The health center exceeded its minimum goal of attaining Level 1 Patient-Centered Medical Home and attained Level 2 in fall 2013. The health center is now working towards Level 3 recognition.

Holyoke Health Center, Chicopee, Holyoke

$75,000 • Developed Azara DRVS data reporting and visualization system.

• Received technical assistance to address billing issues and reengineer financial systems.

Holyoke enhanced system configurations and developed Azara DRVS data reporting systems, which have led to greater data for analysis in clinical programming and has better positioned the health center to analyze upcoming payment reforms. The health center has implemented improvements that lead to enhanced revenue collection. This change in system has increased revenue and 93 percent of billings are now collected.

Joseph M. Smith Community Health Center (JMSCHC), Boston, Waltham

$125,000 • Enhanced processes for referral tracking and follow-up.

• Purchased a new Storage Area Network (SAN) for computer network to increase efficiencies and to successfully implement additional technologies to support quality improvement initiatives.

JMSCHC created a sustainable system for tracking referrals made to Children’s Hospital. At the beginning of the project, approximately 25 percent of specialist notes were returned. As a result of the grant, 80-90 percent of notes are returned and average time for receipt has improved from 52 to 17 days. JMSCHC built and piloted a high-functioning, small-scale model for tracking referrals, which it plans to bring to scale at its largest site with minimal disruption.

Lowell Community Health Center,Lowell

$150,000 • Implemented a reporting and dashboard solution to make better business and patient population management decisions.

• Created more efficient reporting processes.

• Prepared to address future reporting requirements.

• Trained staff on report generation.

Lowell implemented a complex reporting and dashboard solution which has enabled the health center to bring data together from disparate systems and to present relevant, actionable information to providers and staff who can directly improve operations and patient care. This project will have a long-lasting impact on patient care and experience.

North Shore Community Health, Inc. (NSCI), Gloucester, Peabody, Salem

$100,000 • Hired a Medical Director of Health Informatics.

• Expanded interfaces with hospitals and made improvements to current EMR reports and workflows.

NSCI updated its EMR successfully and developed new workflows to create efficiencies for provider reporting. The health center implemented a Patient-Centered Medical Home management plan and care plans to assist providers in more effectively tracking patient goals. The new reports and workflows meet several goals simultaneously: external requirements (such as Patient-Centered Medical Home reporting), tools to engage patients (integrated self-management plans), and care continuity (take-home care plans).

South End Community Health Center (SECHC), Boston

$100,000 • Hired a Meaningful Use consultant to help achieve standards.

• Hired a new Director of Quality.


SECHC achieved Meaningful Use Stage 1 for all providers and created a permanent Director of Quality position, laying the foundation for a culture of quality improvement at the health center. The health center also implemented AZARA DRVS, which enables it to benchmark outcomes against other health centers.

Upham’s Corner Health Center (UCHC),Boston

$100,000 • Converted EMR from Longitudinal Medical Record (LMR) to Centricity and received technical support.

• Implemented AZARA DRVS.

• Trained staff on Crystal Reports.

UCHC successfully converted its EMR system from LMR to GE Centricity. It implemented AZARA DRVS for quality reporting on clinical measures and provided two Crystal Reports trainings which allowed staff to create custom reports to assess quality of care. The new EMR has enabled the health center to coordinate clinical information with BMC and allows providers to e-prescribe.


TABLE 2

Partnership for Community Health 2013 Outcomes - Meaningful Use Implementation


Cambridge Health Alliance Health Centers (CHA), Cambridge, Malden, Revere, Somerville

$125,000 • Expanded patient portal use in preparation for Meaningful Use Stage 2.

• Conducted patient focus groups and surveys for feedback.

• Provided computer workstations and education materials for patient engagement.

• Trained staff.

CHA targeted four of its sites for increased engagement with its patient portal and sought feedback from patients. The health center also created marketing and education brochures, videos and posters to convey information about the patient portal, and how to use it. As a result, the health center achieved a combined increase of 52 percent in patient portal usage over the previous year. The sites are now in a position to reach Meaningful Use Stage 2 objectives as portal usage increases.

Caring Health Center (CHC), Springfield $75,000 • Purchased EMR software.

• Implemented EMR.

• Trained 150 staff.

CHC implemented a new EMR, a major component of the Patient-Centered Medical Home model and a central focus for Meaningful Use. As a result, the health center achieved Meaningful Use Stage 1 and began to receive the associated incentive payments. The majority of its prescriptions are now e-prescribed and lab work is now ordered electronically, which has created efficiencies in health center operations and has increased patient satisfaction.

Codman Square Health Center, Boston $125,000 • Hired a consultant to audit and redesign workflow to include Meaningful Use items.

• Developed new EMR forms.

• Provided Meaningful Use training.

Codman Square and Dorchester House modified their EMR report forms to include Meaningful Use items and monitored the reports weekly, which allowed the health centers to move forward in the Meaningful Use attestation. The health centers also developed forms related to Patient-Centered Medical Home which will allow the health centers to maintain their Level-3 recognition.

Community Health Center of Franklin County (CHCFC), Greenfield, Orange, Turners Falls

$30,000 • Purchased equipment.

• Provided training and staff time on Meaningful Use objectives.

CHCFC improved infrastructure and developed reports and dashboards to monitor clinical quality measures for Meaningful Use. The health center has experienced an increase in patient satisfaction scores and the grant enabled providers to select clinical measures for Meaningful Use Stage 2.

Family HealthCare Center at SSTAR,Fall River

$75,000 • Improved and stabilized IT infrastructure necessary for Meaningful Use Stage 1 and 2.


SSTAR implemented a stable, virtual server which will allow the health center to upgrade its version of NextGen, and move forward with Meaningful Use and ICD-10 implementation. The health center is actively enrolling patients in the patient portal.

Fenway Community Health Center, Boston

$50,000 • Improved IT infrastructure necessary for Meaningful Use Stage 1 and 2.

• Prepared for electronic prescribing of controlled substances for Meaningful Use 2016.

Fenway Health implemented Meaningful Use Stage 2-compliant software and readied for electronic prescribing of controlled substances, which is expected to be included among Meaningful Use measures in 2016. The new system aims to improve patient health outcomes by monitoring the use of controlled substances, checking for potentially harmful medication interactions, and preventing fraud and abuse, while reducing the time required to process prescriptions of controlled substances.

Greater New Bedford Community Health Center (GNBCHC), New Bedford

$125,000 • Hired consultants for coding training and software.

• Implemented patient portal for Meaningful Use.

GNBCHC upgraded to a Meaningful Use Stage 2-compliant EMR and implemented a patient portal, which will provide patients with an alternative opportunity to engage in care. The health center was able to web-enable 1,764 patients for the patient portal with 561 successful logins and 754 individual labs were reviewed in the new portal during the grant period.

Greater Roslindale Medical & Dental Center (GRMDC), Boston

$100,000 • Upgraded to an EMR platform certified for Meaningful Use for both medical and dental.


GRMDC moved its dental department from paper to electronic charting. Implementation and utilization of the new system has enhanced both the provider and patient experience, and allows for more time to interact with new patients and to plan treatment. In addition, the health center implemented Azara DRVS.

Harvard Street Neighborhood Health Center, Boston

$75,000 • Upgraded to a certified platform of EMR.

• Trained all eligible providers and support personnel.

• Established a system to meet Meaningful Use criteria and clinical quality measures.

Harvard Street successfully implemented a Meaningful Use-certified and ICD 10-compliant EMR, Athenahealth. Staff input the necessary data to begin collecting and monitoring Meaningful Use objectives. The new system also includes a patient portal.

HealthFirst Family Care Center,Fall River

$75,000 • Implemented EMR for medical and dental services.

• Trained staff.

HealthFirst implemented an electronic record for medical and dental services and provided trainings for staff, which allowed the health center to meet Meaningful Use measures and to increase the quality of care. Digital technology has lessened patient wait times from 20 to 5 minutes for dental radiographs and has facilitated increased communication with patients on treatment plans.

Lynn Community Health Center (LCHC),Lynn

$150,000 • Improved IT infrastructure necessary for Meaningful Use Stage 1.

• Improved the security of protected electronic health information.

LCHC improved its IT infrastructure by securing communication channels, back-up and disaster recovery and protocols, which enabled 52 of the 53 LCHC providers successfully to meet Meaningful Use Stage 1 objectives.

MGH Community Health Associates,Charlestown, Chelsea, Revere & Everett

$150,000 • Increased access to patient portal.

• Improved patient satisfaction with use of portal for expedited requests.

• Reduced health disparities.

MGH implemented its Patient Gateway and Health Education Project which introduced iPads and kiosk computers into each health center practice to improve access to the Patient Gateway (portal). The health centers developed multilingual education materials on wellness and chronic disease management. Patient enrollment in the Patient Gateway increased by 27 percent, exceeding its goal of 15 percent. The health centers also developed and implemented a low-literacy booklet with instructions on accessing the portal.

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TABLE 2



Cambridge Health Alliance Health Centers (CHA), Cambridge, Malden, Revere, Somerville

$125,000 • Expanded patient portal use in preparation for Meaningful Use Stage 2.

• Conducted patient focus groups and surveys for feedback.

• Provided computer workstations and education materials for patient engagement.

• Trained staff.

CHA targeted four of its sites for increased engagement with its patient portal and sought feedback from patients. The health center also created marketing and education brochures, videos and posters to convey information about the patient portal, and how to use it. As a result, the health center achieved a combined increase of 52 percent in patient portal usage over the previous year. The sites are now in a position to reach Meaningful Use Stage 2 objectives as portal usage increases.

Caring Health Center (CHC), Springfield $75,000 • Purchased EMR software.

• Implemented EMR.

• Trained 150 staff.

CHC implemented a new EMR, a major component of the Patient-Centered Medical Home model and a central focus for Meaningful Use. As a result, the health center achieved Meaningful Use Stage 1 and began to receive the associated incentive payments. The majority of its prescriptions are now e-prescribed and lab work is now ordered electronically, which has created efficiencies in health center operations and has increased patient satisfaction.

Codman Square Health Center, Boston $125,000 • Hired a consultant to audit and redesign workflow to include Meaningful Use items.

• Developed new EMR forms.

• Provided Meaningful Use training.

Codman Square and Dorchester House modified their EMR report forms to include Meaningful Use items and monitored the reports weekly, which allowed the health centers to move forward in the Meaningful Use attestation. The health centers also developed forms related to Patient-Centered Medical Home which will allow the health centers to maintain their Level-3 recognition.

Community Health Center of Franklin County (CHCFC), Greenfield, Orange, Turners Falls

$30,000 • Purchased equipment.

• Provided training and staff time on Meaningful Use objectives.

CHCFC improved infrastructure and developed reports and dashboards to monitor clinical quality measures for Meaningful Use. The health center has experienced an increase in patient satisfaction scores and the grant enabled providers to select clinical measures for Meaningful Use Stage 2.

Family HealthCare Center at SSTAR,Fall River

$75,000 • Improved and stabilized IT infrastructure necessary for Meaningful Use Stage 1 and 2.


SSTAR implemented a stable, virtual server which will allow the health center to upgrade its version of NextGen, and move forward with Meaningful Use and ICD-10 implementation. The health center is actively enrolling patients in the patient portal.

Fenway Community Health Center, Boston

$50,000 • Improved IT infrastructure necessary for Meaningful Use Stage 1 and 2.

• Prepared for electronic prescribing of controlled substances for Meaningful Use 2016.

Fenway Health implemented Meaningful Use Stage 2-compliant software and readied for electronic prescribing of controlled substances, which is expected to be included among Meaningful Use measures in 2016. The new system aims to improve patient health outcomes by monitoring the use of controlled substances, checking for potentially harmful medication interactions, and preventing fraud and abuse, while reducing the time required to process prescriptions of controlled substances.

Greater New Bedford Community Health Center (GNBCHC), New Bedford

$125,000 • Hired consultants for coding training and software.

• Implemented patient portal for Meaningful Use.

GNBCHC upgraded to a Meaningful Use Stage 2-compliant EMR and implemented a patient portal, which will provide patients with an alternative opportunity to engage in care. The health center was able to web-enable 1,764 patients for the patient portal with 561 successful logins and 754 individual labs were reviewed in the new portal during the grant period.

Greater Roslindale Medical & Dental Center (GRMDC), Boston

$100,000 • Upgraded to an EMR platform certified for Meaningful Use for both medical and dental.


GRMDC moved its dental department from paper to electronic charting. Implementation and utilization of the new system has enhanced both the provider and patient experience, and allows for more time to interact with new patients and to plan treatment. In addition, the health center implemented Azara DRVS.

Harvard Street Neighborhood Health Center, Boston

$75,000 • Upgraded to a certified platform of EMR.

• Trained all eligible providers and support personnel.

• Established a system to meet Meaningful Use criteria and clinical quality measures.

Harvard Street successfully implemented a Meaningful Use-certified and ICD 10-compliant EMR, Athenahealth. Staff input the necessary data to begin collecting and monitoring Meaningful Use objectives. The new system also includes a patient portal.

HealthFirst Family Care Center,Fall River

$75,000 • Implemented EMR for medical and dental services.

• Trained staff.

HealthFirst implemented an electronic record for medical and dental services and provided trainings for staff, which allowed the health center to meet Meaningful Use measures and to increase the quality of care. Digital technology has lessened patient wait times from 20 to 5 minutes for dental radiographs and has facilitated increased communication with patients on treatment plans.

Lynn Community Health Center (LCHC),Lynn

$150,000 • Improved IT infrastructure necessary for Meaningful Use Stage 1.

• Improved the security of protected electronic health information.

LCHC improved its IT infrastructure by securing communication channels, back-up and disaster recovery and protocols, which enabled 52 of the 53 LCHC providers successfully to meet Meaningful Use Stage 1 objectives.

MGH Community Health Associates,Charlestown, Chelsea, Revere & Everett

$150,000 • Increased access to patient portal.

• Improved patient satisfaction with use of portal for expedited requests.

• Reduced health disparities.

MGH implemented its Patient Gateway and Health Education Project which introduced iPads and kiosk computers into each health center practice to improve access to the Patient Gateway (portal). The health centers developed multilingual education materials on wellness and chronic disease management. Patient enrollment in the Patient Gateway increased by 27 percent, exceeding its goal of 15 percent. The health centers also developed and implemented a low-literacy booklet with instructions on accessing the portal.

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TABLE 2 continued



Martha Eliot Health Center, Boston $125,000 • Improved quality reporting capabilities to monitor Meaningful Use objectives.

• Hired quality improvement assistant, now a permanent position.

Martha Eliot improved quality reporting capabilities related to Meaningful Use. The health center adopted a set of measures to monitor process and outcomes measured over time, and is engaging care teams to design and test quality and outreach improvements and track the impact on care. Over the grant period, the health center has increased well-child visits by 93 percent, exceeding its goal of 75 percent. The funding afforded the health center the time and resources to develop a quality improvement program and begin to train staff on how to implement interventions to improve operations and care. The successes lead to a new hospital-funded, quality improvement position at the health center.

Mattapan Community Health Center (MCHC), Boston

$50,000 • Purchased Meaningful Use-compliant software.

• Provided training.

• Developed CQM reporting including PHI data protection HIPAA compliance.

MCHC engaged a consultant to assess the health center’s Meaningful Use readiness, adjust workflows, and develop the necessary reports to monitor Meaningful Use clinical quality measures. The health center also used grant funding to connect to Azara DRVS.

Roxbury Comprehensive Community Health Center, Boston

$25,000 • Developed forms for Meaningful Use measurement and provided training for IT staff. Roxbury Comprehensive Community Health Center closed during the grant period.

Springfield Health Services for the Homeless Health Center, Springfield

$30,000 • Moved EMR system from the city-hosted server to an out-sourced data center.

• Improved practice management and EMR applications to comply with Meaningful Use.

Springfield successfully moved its EMR server and has contracted an externally managed service which enabled the health center to provide more seamless services for patients.

South Cove Community Health Center,Boston, Quincy

$125,000 • Expanded medical home model to two additional sites.

• Prepared eligible providers to qualify for Meaninful Use Stage 1.

South Cove received full NCQA Level-3 Patient-Centered Medical Home status for all three of its sites, and providers were approved for Meaningful Use Stage 1. The grant allowed the health center to standardize data entry in the EMR for Meaningful Use and it will ensure that patients receive the highest-quality of care. The health center added two pharmacists and two pharmacy techs to its team and ensured that patients who receive medications receive culturally competent explanations from doctors, nurses, and pharmacy. By becoming a Level-3 medical home and certified meaningful users of its EMR, the health center is better positioned to bring high-quality, low-cost care to a vulnerable population.

TABLE 3

Partnership for Community Health 2013 Outcomes - Coding Training


Baystate Medical Center Health Centers,Springfield

$20,000 • Provided a train-the-trainer ICD-10 boot camp to staff and participated in web-based AAPC courses.

• Purchased needed training manuals and tools.

Baystate provided a train-the-trainer boot camp for its billers, coders, practice managers, and providers on ICD-10 coding. The increased capacity in coding will positively impact revenue at the health center.

Boston Health Care for the Homeless Program (BHCHP), Boston

$30,000 • Assessed coding practices of providers and nurses.

• Provided coding training.

• Developed internal resources in coding and auditing.

BHCHP provided a coding course, trainings, and an outside consultant conducted a chart audit. Nurses have now received training which positively impacts coding and billing. The health center Coding Specialist became a Certified Professional Coder, which is invaluable to the organization as it will now have capacity for internal audits, which could help save health center resources in the long term.

Community Health Programs (CHP),Great Barrington, Lee, Pittsfield

$20,000 • Improved coding across its five health centers through chart audits and training. CHP improved coding, documentation, and billing at its five health centers which has helped to increase appropriate reimbursement and improve the accuracy of patient records. The project has significantly improved OB/GYN coding and documentation. As a result, OB/GYN, which had been losing money each year since 2009, met its budgeted goal just halfway through the year. Moreover, the grant helped CHP to capture more than $5,000 in additional revenue each month for tasks that were done but had not been properly documented.

Dimock Community Health Center,Boston

$75,000 • Hired a Quality Improvement Case Manager/ Compliance Officer.

• Built internal population health management and data capacity, focused on two chronic disease areas: hypertension and pediatric asthma.

Dimock hired a Quality Improvement/Compliance officer and conducted a coding audit with a focus on hypertension and asthma. As a result of this effort, the health center surpassed its hypertension blood pressure control rate of 60 percent. It also surpassed its goal of 65 percent of asthma patients on controller medications and reached 90 percent. Adult medicine went from 65 to 88 percent in 'coding matches' and pediatrics went from 62 to 76 percent in calendar year 2013. The project will help the health center determine patterns in coding gaps, identify training needs, and track coding compliance over time. The improved coding compliance will also help to refine registry outreach, improve accuracy in billing and in-risk scores.

Dorchester House Multi-Service Center,Boston

$100,000 • Provided coding training.

• Developed coding cheat sheets and software.

• Documented workflow protocols.

Dorchester House engaged a consultant to advise, plan, and conduct a coding improvement project. The consultant performed an analysis of practices and from their assessment, the health center redesigned workflows and provided additional training for staff and hired a full-time coding analyst to gauge success and develop performance improvement on an ongoing basis. As a result, collection rates have increased and turnaround times have improved as a result.

Greater Lawrence Family Health Center (GLFHC), Lawrence

$150,000 • Conducted audits on 92 of 140 providers.

• Identified gaps/issues with coding.

• Trained staff.

• Created systems for proper coding.

GLFHC conducted a risk adjustment audit, which helped the health center to identify areas for improvement, such as proper coding when billing for diabetes with a manifestation, chronic kidney disease, and depression. Based on the findings from the audit, GLFHC has modified its trainings to further support coding.

South Boston Community Health Center (SBCHC), Boston

$100,000 • Provided coding trainings.

• Improved continuity of provider teams.

SBCHC provided coding trainings for its providers which helped the health center to prepare for the upcoming ICD-10 transition, and providers are now more knowledgeable about risk-adjusted coding. The health center also worked on the continuity of provider teams for patients and patients have reported increased satisfaction seeing the same primary care team at each visit.


TABLE 2 continued



Martha Eliot Health Center, Boston $125,000 • Improved quality reporting capabilities to monitor Meaningful Use objectives.

• Hired quality improvement assistant, now a permanent position.

Martha Eliot improved quality reporting capabilities related to Meaningful Use. The health center adopted a set of measures to monitor process and outcomes measured over time, and is engaging care teams to design and test quality and outreach improvements and track the impact on care. Over the grant period, the health center has increased well-child visits by 93 percent, exceeding its goal of 75 percent. The funding afforded the health center the time and resources to develop a quality improvement program and begin to train staff on how to implement interventions to improve operations and care. The successes lead to a new hospital-funded, quality improvement position at the health center.

Mattapan Community Health Center (MCHC), Boston

$50,000 • Purchased Meaningful Use-compliant software.

• Provided training.

• Developed CQM reporting including PHI data protection HIPAA compliance.

MCHC engaged a consultant to assess the health center’s Meaningful Use readiness, adjust workflows, and develop the necessary reports to monitor Meaningful Use clinical quality measures. The health center also used grant funding to connect to Azara DRVS.

Roxbury Comprehensive Community Health Center, Boston

$25,000 • Developed forms for Meaningful Use measurement and provided training for IT staff. Roxbury Comprehensive Community Health Center closed during the grant period.

Springfield Health Services for the Homeless Health Center, Springfield

$30,000 • Moved EMR system from the city-hosted server to an out-sourced data center.

• Improved practice management and EMR applications to comply with Meaningful Use.

Springfield successfully moved its EMR server and has contracted an externally managed service which enabled the health center to provide more seamless services for patients.

South Cove Community Health Center,Boston, Quincy

$125,000 • Expanded medical home model to two additional sites.

• Prepared eligible providers to qualify for Meaninful Use Stage 1.

South Cove received full NCQA Level-3 Patient-Centered Medical Home status for all three of its sites, and providers were approved for Meaningful Use Stage 1. The grant allowed the health center to standardize data entry in the EMR for Meaningful Use and it will ensure that patients receive the highest-quality of care. The health center added two pharmacists and two pharmacy techs to its team and ensured that patients who receive medications receive culturally competent explanations from doctors, nurses, and pharmacy. By becoming a Level-3 medical home and certified meaningful users of its EMR, the health center is better positioned to bring high-quality, low-cost care to a vulnerable population.

TABLE 3

Partnership for Community Health 2013 Outcomes - Coding Training


Baystate Medical Center Health Centers,Springfield

$20,000 • Provided a train-the-trainer ICD-10 boot camp to staff and participated in web-based AAPC courses.

• Purchased needed training manuals and tools.

Baystate provided a train-the-trainer boot camp for its billers, coders, practice managers, and providers on ICD-10 coding. The increased capacity in coding will positively impact revenue at the health center.

Boston Health Care for the Homeless Program (BHCHP), Boston

$30,000 • Assessed coding practices of providers and nurses.


• Developed internal resources in coding and auditing.

BHCHP provided a coding course, trainings, and an outside consultant conducted a chart audit. Nurses have now received training which positively impacts coding and billing. The health center Coding Specialist became a Certified Professional Coder, which is invaluable to the organization as it will now have capacity for internal audits, which could help save health center resources in the long term.

Community Health Programs (CHP),Great Barrington, Lee, Pittsfield

$20,000 • Improved coding across its five health centers through chart audits and training. CHP improved coding, documentation, and billing at its five health centers which has helped to increase appropriate reimbursement and improve the accuracy of patient records. The project has significantly improved OB/GYN coding and documentation. As a result, OB/GYN, which had been losing money each year since 2009, met its budgeted goal just halfway through the year. Moreover, the grant helped CHP to capture more than $5,000 in additional revenue each month for tasks that were done but had not been properly documented.

Dimock Community Health Center,Boston

$75,000 • Hired a Quality Improvement Case Manager/ Compliance Officer.

• Built internal population health management and data capacity, focused on two chronic disease areas: hypertension and pediatric asthma.

Dimock hired a Quality Improvement/Compliance officer and conducted a coding audit with a focus on hypertension and asthma. As a result of this effort, the health center surpassed its hypertension blood pressure control rate of 60 percent. It also surpassed its goal of 65 percent of asthma patients on controller medications and reached 90 percent. Adult medicine went from 65 to 88 percent in 'coding matches' and pediatrics went from 62 to 76 percent in calendar year 2013. The project will help the health center determine patterns in coding gaps, identify training needs, and track coding compliance over time. The improved coding compliance will also help to refine registry outreach, improve accuracy in billing and in-risk scores.

Dorchester House Multi-Service Center,Boston

$100,000 • Provided coding training.

• Developed coding cheat sheets and software.

• Documented workflow protocols.

Dorchester House engaged a consultant to advise, plan, and conduct a coding improvement project. The consultant performed an analysis of practices and from their assessment, the health center redesigned workflows and provided additional training for staff and hired a full-time coding analyst to gauge success and develop performance improvement on an ongoing basis. As a result, collection rates have increased and turnaround times have improved as a result.

Greater Lawrence Family Health Center (GLFHC), Lawrence

$150,000 • Conducted audits on 92 of 140 providers.

• Identified gaps/issues with coding.

• Trained staff.

• Created systems for proper coding.

GLFHC conducted a risk adjustment audit, which helped the health center to identify areas for improvement, such as proper coding when billing for diabetes with a manifestation, chronic kidney disease, and depression. Based on the findings from the audit, GLFHC has modified its trainings to further support coding.

South Boston Community Health Center (SBCHC), Boston

$100,000 • Provided coding trainings.

• Improved continuity of provider teams.

SBCHC provided coding trainings for its providers which helped the health center to prepare for the upcoming ICD-10 transition, and providers are now more knowledgeable about risk-adjusted coding. The health center also worked on the continuity of provider teams for patients and patients have reported increased satisfaction seeing the same primary care team at each visit.


TABLE 4

Partnership for Community Health 2013 Outcomes - Training and Capacity Building for Performance Improvement


Brookside Community Health Center,Boston

$125,000 • Hired a quality improvement facilitator.

• Provided training using train-the-trainer model and applying LEAN principles.

• Conducted medical records review.

Brookside hired a quality improvement trainer to develop internal capacity on LEAN and quality improvement strategies for the health center, with a focus on primary care. The health center also hired an outside consultant to conduct record reviews and to train staff on the most current coding practices. 11 of its 13 clinicians scored a 90 percent or better in the audits, a very successful finding (the remaining 2 clinicians scored 80 percent).

Bowdoin Street Health Center, Boston $75,000 • Hired a full-time nurse to focus on the care management of high-risk patients. Bowdoin Street improved and extended the benefits of its Patient-Centered Medical Home to additional patients by adding a full-time nurse to focus on the standardization of assessments, care planning, action plans, and individualized interventions. As a result, the health center increased access to care management services from 176 patients in 2012 to 319 patients in 2013. NHP patient outcomes have modestly improved as a result, with LDL screenings up from 80 to 84 percent and retinal screenings from 56 to 65 percent.

Harbor Health Service – Geiger Gibson Community Health Center (GGCHC),Boston

$50,000 • Implemented a centralized call center for three health centers. GGCHC built and developed the headquarters for its agency-wide call center, providing information and connecting patients with providers. The health center achieved a 95 percent answer rate and reduced call complaints from 50 to 5 percent. As a result, the health center improved communication between patients and providers, which is core to Patient-Centered Medical Home practice transformation.

Harbor Health Services – Harbor Health Center, Hyannis

$30,000 • Enabled medical staff to function as a multidisciplinary care coordination team, advancing the effectiveness of its Patient-Centered Medical Home Model.

• Created curricula and training.

HCHCH implemented a training program for nurses and clinical support staff to function as a multidisciplinary Patient-Centered Medical Home. The training increased provider efficiency and helped to prepare for Primary Care Reform, global payments and the provider requirements of the Affordable Care Act, further advancing its work towards the Patient-Centered Medical Home model.

Harbor Health Services–Neponset Health Center (NHC), Boston

$100,000 • Established a training and capacity building program to give nurses and care coordinators the skills to function as a multidisciplinary Patient-Centered Medical Home team.

NHC implemented a training program for nurses and clinical support staff to function as a multidisciplinary Patient-Centered Medical Home. The funding offered an important opportunity for the health center to enhance the capability and Patient-Centered Medical Home awareness for clinical care managers (RNs) and care coordinators.

Hilltown Community Health Centers (HCHC), Huntington, Worthington

$30,000 • Trained staff on LEAN quality improvement principles.


HCHC provided coding training and certified its billing manger as a coder to better understand the ICD-10 workflow. Seven staff received introductory LEAN training, which has improved service to patients by helping create a more robust quality improvement policy and workflow. The health center has also improved revenue capture by increasing coding capacity.

Island Health Care (IHC), Edgartown $30,000 • Trained staff on and incorporated Chronic Care Model (CCM) using the proven CCM’s Plan/Do/Study/Act (PDSA) process.

IHC successfully trained staff and phased-in a Chronic Care Model (CCM), which includes collaborative goal setting and problem-solving during which the patient is informed and plays an active role. The health center incorporated four of the six CCM components (67 percent) into its daily flow, leaving clinical information systems and electronic patient registry still works in progress. The health center was also able to leverage concurrent activities and bring in health coaching, patient chronic disease management and nutrition classes, producing a “one-stop shopping” environment for chronic disease patients, increasing the rate of successful referrals to self-management services.

Manet Community Health Center,Hull, Quincy

$125,000 • Expanded nurse care management and care coordination.

• Hired a lead care management nurse.

• Established a care management review team with the goal to reach Level-3 Patient-Centered Medical Home at all sites.

Manet hired a nurse care manager at each of its five sites. Its largest site, North Quincy, was awarded Level-2 Patient-Centered Medical Home and the health center is working towards Level-3 at all of its sites. The health center also created new dashboards in its EMR which are discussed at health care utilization review meetings and provided to care managers for targeted outreach to patients.

North End Waterfront Health (NEW),Boston

$50,000 • Hired an RN Quality Care Manager to oversee the implementation of multiple performance improvement initiatives.

NEW hired an RN Quality Care Manager and developed a pre-screen tool to ensure screening part of every visit and is not provider-dependent. As a result, NEW has improved its PAP smear compliance from 48 to 98 percent and improved colonoscopy protocol compliance from 38 to 66 percent for female patients.

Outer Cape Health Services, Inc. (OCHS ), Harwich, Provincetown, Wellfleet

$50,000 • Provided LEAN training through the Massachusetts League of Community Health Centers.

OCHS provided LEAN training to staff, identified a patient flow improvement project, and worked it through the LEAN quality improvement process. As a result, the health center has reduced patient wait time from an all-time high of 3.2 hours to 30 minutes for walk-in patients.

Southern Jamaica Plain Health Center,Boston

$100,000 • Provided training to all staff on a variety of skills needed for quality improvement efforts, particularly for Patient-Centered Medical Home.

SJPHC hired a Training Specialist to provide staff training on a range of topics including LEAN, Customer Service for Practice Assistants, Team Building, Motivational Interviewing and specialized MI training for doctors. Additionally, staff were trained in Excel skills as well as the social determinants of health. The project has dramatically changed the culture of the health center, with frontline staff being empowered and trained to participate in improvement processes. The health center will complete its Patient-Centered Medical Home submission with NCQA in October.

Whittier Street Health Center, Boston $100,000 • Identified and developed protocol to track high-risk patients.

• Developed a self-care and care management initiative for asthma and depression, managed by an RN case manager.

Whittier Street increased its capacity to provide case management services to high-risk patients by adding a new RN and case manager. The health center identified a high-risk patient panel, provided case management, and continuously monitored health outcomes. Through this effort, the health center increased the percentage of patients with an annual physical and care plan from 41 percent to 62 percent and clinical summaries are now printed for 83 percent of patients, up from 73 percent.

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