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Podcast Library > NextGen Advisors Podcasts > How Community Health Centers Can Lead the Way in a New Era of Healthcare

July 24, 2020

How Community Health Centers Can Lead the Way in a New Era of Healthcare

In this episode, the NextGen® Advisors discuss key takeaways from a recent webinar with leaders from various community health centers across the U.S. They discuss how CHCs are evolving to meet the needs of their communities and addressing changes in the national healthcare system, as well as rising to the challenges of the current COVID-19 health crisis.

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Transcript

Dr. Betty Rabinowitz:

Hello, this is Dr. Betty Rabinowitz, NextGen Healthcare's chief medical officer and principal with NextGen Advisors. I'd like to welcome you to our podcast series featuring senior leaders from the NextGen Advisors team. In this series, we address different subjects related to ambulatory care, the successes, the challenges, community providers' experience, from an operation's policy and strategy perspective. I'm joined today by Graham Brown and Dr. Marty Lustick. Welcome, Graham and Marty.

Graham Brown:

Good morning, Betty.

Dr. Martin Lustick:

Hi, Betty.

Dr. Betty Rabinowitz:

This week, NextGen Advisors conducted a webinar for community health clinics across the country. The topic of the webinar was how community health centers can lead the way in a new era of healthcare. My first question to you would be do you actually believe that CHCs can lead the way in a new era of healthcare? And, if so, what is it about CHCs that positions them to do so? Marty?

Dr. Martin Lustick:

I actually do believe that they can lead the way, and I would say that if you'd asked me the same question five years ago, I would not have been in that place at all. But I think, given the level of growth we've seen in CHCs and the ability of some of them to truly integrate behavioral health with primary care, as well as their dental services, and to improve their ability to integrate with other resources in the community, as you look at the challenges that traditional private practice primary care offices face, they really can look to CHCs as a model for how they might want to evolve going forward.

Dr. Betty Rabinowitz:

Graham?

Graham Brown:

Yeah, it's an interesting observation Marty makes in terms of whether community health centers really were positioned to be leading the way five years ago versus where they are now. I agree, I think there's been a real change in the role of community health centers in communities because of the integrated nature of the services that they provide. And truly, they are in a position because they are community-based and serving those who have access issues, combined social determinants of health, as well as medical issues, being able to provide, really, a comprehensive approach to care and a patient-centered model of care is, I think, really core to their success and why, for patients, it's such an attractive option. Being able to go to one provider, it's like a one-stop shop, where you know you can get directly connected to the kind of services that you need, as a person living in a community, without having to go to either multiple different providers or work with a larger health system and get into the hospital construct. So being able to serve patients in community comprehensively, I think is really unique to their model that's positioned them well.

Dr. Betty Rabinowitz:

Yeah, absolutely. It's interesting, when you look at the numbers regarding quality and cost of these community health centers, they're incredibly favorable. There is both some good evidence of high-quality care being provided in cost-effective manner, so clearly, they have found a equation for a formula for very successful community-based, community-centered care. In the recent webinar we have been referencing, we were joined by three leaders from federally-qualified health centers across the country who each spoke about the innovations that are setting them on course for success and leadership. Ray Lavoie, the executive director at Blackstone Valley Community Health Care, talked about the urban health station model they've implemented in Rhode Island. What struck you about this model of care? Grant?

Graham Brown:

Again, this is a really well-designed, integrated model of care. So from a practice and specialty perspective, the services that were combined was very interesting. It's a new building, and they built this space in an urban environment where they recognize many of the clients they would be serving wouldn't have transportation and so would be walking to this center. And so they recognized location wise and geographically that they wanted to put it right in the heart of the community that needed to be served. They also recognized in building and designing this space that there was a need for culturally-appropriate services. They've got a very high population of folks from Cape Verde, as well as a Portuguese population. So they've got language interpreting services but have other services that are very specific to serving that community. The other thing that was interesting was because it's a fairly large space, they've co-located other service providers within the building itself and so have community services for social determinants of health, people being able to access other services in their plans of how the space itself will be developed over time to serve the broader needs beyond just the medical services that Blackstone Valley themselves are providing.

Dr. Martin Lustick:

So, I think those are really important points, Graham, and I would build on your comments about having available other services, such as social determinants of health. And they combine that with their goal of serving 90% of the population of the community that they're residing in. And I found that a really fascinating attribute of the model because, in many ways, the idea of having a single health system for a community and not competing providers that are also integrating with other services, really positions the health facility and the health services as being a part of what is the fabric of the community and part of the glue that holds that community together and, at the same time, affords them the opportunity to track public health issues if they're caring for that large of a proportion of the population to integrate with the public health needs of the community in ways that most healthcare providers have really not done to this point.

Dr. Betty Rabinowitz:

I think that's a great point, Marty. It was fascinating to me to hear the excitement that Ray described of having a database that included so much wisdom about these patients, concentrated in a single location that's accessible to all the patient providers that covers an entire community, really a utopian view of a data-rich, interconnected, interoperable delivery system. It was extremely impressive. One of the challenges, though, that Ray touched on was evolving the clinical model and keeping it aligned with payment models. He seemed pretty disillusioned with the fee-for-service model. What did you take away from his comments about that, Marty?

Dr. Martin Lustick:

I thought what was most striking was how community health clinics, in some way, are a dramatic example of what most providers experience, which is the way they provide care is shaped by the way they're paid. For community health clinics, because what they get paid for has been very prescribed by the government and by regulations, they've been under constraints, for example, that they couldn't provide telephonic care or virtual visits, other than for behavioral health. Ray was relating in Rhode Island, that they've done this for a while in behavioral health, but until the pandemic, and they were allowed to do this for other services and get reimbursed, they really couldn't afford to provide care in that way. And, for me, the frustration that I heard from Ray was they have the ability to continue to evolve their model and dramatically improve the way they give care, but if they're constrained by having to understand which widgets they'll get paid for and which ones they won't, they're never going to be able to realize their potential. And he pretty clearly stated that he thinks that a prepayment model would be much better. It would give them reliable revenue and free them up to give them the flexibility to continuously improve.

Graham Brown:

Yeah, we just add on to the concept of that flexibility. I think the fee-for-service model that this community health center, and many others, are working under really challenges them to report on various different measures that might be arbitrary in relation to the care provided. There's so many administrative hoops to jump through, so many different payers that they need to work with different schedules, with different types of payment for different services and how providers need to really navigate and spend so much time and energy navigating that world. I imagine that's part of his frustration. Moving to a simpler model of care, which Ray was advocating, in terms of a perspective payment, where really the practice is focused on the patients, their clinical care, and their outcomes and not on managing the dollar flow and how to ensure that they get paid and dealing with collections and patients that may want to pay for their car, but can't afford to. And those challenges really are front and center, I think, with a lot of community health centers, and they're really suffering under an antiquated system that doesn't support the modernization, nor the goals that we're trying to achieve in community-based healthcare.

Dr. Betty Rabinowitz:

Those are very important points, Graham. I think that, generally speaking, post-COVID, there is a recognition as well that having health care delivery organizations of any kind, but certainly community based ones, be so sensitive to volume and so vulnerable to the changes that can occur is not a position we want to be in as a health system, where clinics are so dependent and can be taken down by a lapse in volumes, and that we need to find a payment system that is more resilient and can even out the impacts of the fluctuations in volume, based on a pandemic or any other forces that come to bear. Our second guest was Dr. Sue Ann Park from Vista Community Clinic, just north of San Diego. And Dr. Park spoke quite a bit about how they've integrated a robust behavioral health capability into what was originally a freestanding primary care practice. What did you take away from her story, Marty?

Dr. Martin Lustick:

I think what was most striking to me was the depth of integration that they've been able to achieve over time. That it's not just about getting a trained psychiatric social worker and plopping them into a primary care office and saying, "Now, we've got behavioral health integrated with primary care," but that they have multiple levels of services on the behavioral health side, with technicians, different types of therapists, social workers, and all the way up through to a psychiatrist. And, at the same time, that evolving capacity and capability in the behavioral health has provided training and support for primary care, so that within the medical side, they've been able to improve their screening capabilities and their referral capabilities. It actually reminded me of a while back when I was working with primary care doctors on the patient-centered medical home, and many of them were implementing the PHQ-9 as a screening tool. They were very concerned that if they identified a patient who is depressed, they wouldn't know what to do with them next. And the contrast with what Vista Clinic has evolved into, where there's a natural workflow and it's part of the routine care of patients in primary care, if they're assessed and they have a mental health issue, it's just a natural flow of work to make sure that patient gets the services that they need.

Graham Brown:

One of the things for me that was exciting about what Sue Ann described was how the embedded nature of having behavioral health specialists within that clinic environment really allowed all boats to rise together. She spoke about how even the various different team members that are interacting with the patients were all much more sensitive to what they were hearing from patients. They were able to do some initial screening themselves. It was really built into the culture. And I think the other element that she talked about is during the stress of the pandemic and COVID being involved in their community environment, how resourceful the team was able to be in working with each other together, they really had some of the skills and the coping mechanisms in place. They were able to rely on each other as a team because they built their skillset around their own mental health support and were able to manage their anxieties in a way that really showed how embedded that capability and that knowledge had become, culturally, within their practice. And that was a really exciting and innovative thing for me to hear about.

Dr. Betty Rabinowitz:

Absolutely. Our final guest was to Charles Kitzman, the CIO at Shasta Community Health Center in Northern California. Their pandemic response was informed by prior experiences with both fire and weather disasters in Northern California. What did you think were the most valuable lessons about how to prepare for disasters, in general? Marty?

Dr. Martin Lustick:

One that was loud and clear is communication. Having strong communication among the different functions at the center, as well as transparency and communication with the staff and the patients so that everybody knows what's going on. And you tie that to another critical attribute, which is to be flexible enough to be able to change, on a moment's notice, as the situation evolves so quickly in the midst of a disaster. So combining flexibility with really robust communications is really, to me, the biggest takeaway from all of that.

Graham Brown:

I think the interesting aspect was because of their prior experience with some really difficult disaster situations, they formalized their response and their preparedness into an incident command model, where from the outset, they really had, as Marty was saying, their communication structure, their protocols. All of that thinking had already been done. They weren't having to make it up on the fly. They were flexible enough to recognize things were changing and communicate those changes to their team members, but they put the hard work in upfront to ensure that they were going to have a model that was going to allow them to respond in real time, keep connected to each other, communicate consistently, and clearly around what changes needed to occur. And that advanced preparedness and turning it really into a program of preparedness for them, I think stood them in very good stead heading into COVID.

Dr. Betty Rabinowitz:

Absolutely. Charles also spoke about an innovative project they were implementing to create and populate physician schedules based on several factors, including assessment of the patient's complexity and risk. What are your thoughts of about this project, Graham?

Graham Brown:

Changing a physician's schedule can often be quite fraught with controversy within an organization. And Charles really spoke about how inclusive they were in their approach. He was very conscious to hear the voices of the different types of providers, what their needs were. And they really developed a methodology that for them was evidence-based. It looked at the complexity and the risk, as you were saying, of the patients they were serving. And they tried to bring some standardization and some normality to how all of the providers, collectively, would work together. And I think the thing that, as a chief information officer, Charles really demonstrated his capability was to facilitate that group to bring around the leadership that was necessary to really engage the providers and ensure their buy-in in the model that was going to go forward so that he really avoided the pitfalls that many other organizations fall into when decisions are made in a bubble or made in an arbitrary way that people ultimately don't buy into. And Charles really spoke, I think, in an eloquent manner around how they avoided some of those pitfalls.

Dr. Martin Lustick:

Yeah, I would build on that one to say that Charles is a bit of a special person as a CIO, clearly demonstrating understanding that it's not just about changing the scheduling system from an IT perspective and putting in risk adjustment factors from an IT perspective, but that recruiting and retaining providers and staff and focusing on how to make their lives easier and their workflows smoother, he really sees the big picture. And he incorporates both the people and the concepts into the way the work gets done, and that's very evident from the way he approached the project. The other interesting aspect of this, to me, was that there was a combination of trying to simplify scheduling appointments, which is a big issue in many practices, as it interferes with the ability to keep your schedules full, if you have too many different appointment types, but they actually are integrating that with a risk adjustment model, where the appointment length times are adjusted based on the risk level of each patient. And I thought that was a fascinating concept, so that a doctor's panel size the patient's specific appointment type and length are all linked together in real time. And I'm interested to see how that's going to play out.

Dr. Betty Rabinowitz:

Indeed, changing physician schedules can be very traumatic, and clearly, the hope is that both from a quality perspective and a physician satisfaction and patient satisfaction perspective, they will create a very viable, scalable model that we can all learn from. Thank you, our listeners, for joining us today. I'd like to thank my colleagues, Dr. Marty Lustick and Graham Brown, for sharing their insights and perspectives on the recent webinar. If you enjoyed today's topic, consider subscribing to our podcast. If you'd like to view the webinar we discussed in today's podcast, it can be found on the nextgen.com website. This is Dr. Betty Rabinowitz with NextGen Healthcare. Have a great day.