aapcho board of directors’ meeting aapcho · 2017-02-13 · aapcho cultivating traditions of...

AAPCHO Cultivating Traditions of Wellness

Advancing Community LeadershipMarch 19-20, 2012

AAPCHO Board of Directors’ MeetingWednesday, March 21, 2012

11:00 am - 2:30 pm EDTGovernor’s Board Room

Omni Shoreham HotelWashington, DC

AAPCHO Board of Directors' MeetingWednesday, March 21, 2012

Board Packet - Table of Contents for PDF Version*

*Hard Copies will be provided at the Board of Directors' Meeting

Item PageBoard Meeting Agenda ...................................................................................................2Nomination Letter of New Board Representative: Bay Clinic, Inc. ...............................3Monica Adams Resume ..................................................................................................4Nomination Letter of New Board Representative: Waimanalo Health Center ...............6Mary Oneha Resume .......................................................................................................7Nomination Letter of Consumer at Large: Kamahanahokulani Farrar ...........................10Kamahanahokulani Farrar Resume .................................................................................11Board of Directors’ Meeting Minutes, August 2011 .......................................................16Executive Director Report: September 2011 .................................................................19Executive Director Report: October 2011 .....................................................................22Executive Director Report: November 2011 .................................................................25Executive Director Report: January 2012 ......................................................................27Executive Director Report: February 2012 ....................................................................30BOD Report: 2012 Strategic Plan Update ......................................................................34Mapping Status ...............................................................................................................35AAPCHO Strategic Plan .................................................................................................42BOD Roles & Responsibilities .......................................................................................47CAHPS Issue Brief .........................................................................................................50BOD Report: CHARN/IRB ............................................................................................52CHARN Newsletter, Fall 2011 .......................................................................................53AAPCHO NORC Case Study Report DRAFT ...............................................................60AAPCHO Fact Sheet 2011: IRB ....................................................................................71AAPCHO Fact Sheet 2011: MU ....................................................................................73AAPCHO Fact Sheet 2011: PIC ....................................................................................75AAPCHO Info Sheet 2011: PIC ES ...............................................................................77AAPCHO Info Sheet 2011: P4P ....................................................................................79AAPCHO Fact Sheet 2012: 2010 UDS Fact Sheet .......................................................81NRMC Summary ............................................................................................................83ACO in the Safety-Net ....................................................................................................86NCAPA Policy Blueprint ................................................................................................90

AAPCHO Board of Directors’ Meeting

Wednesday, March 21, 2012 11:00 am – 2:30 pm EDT Governors Board Room Omni Shoreham Hotel

Washington, DC

AGENDA Lunch will be available

I. Welcome and Introductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:00

II. New BOD Member Vote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:10

III. Approve August 2011 Board Minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:15

IV. ED Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:20

V. 2011 Audit Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:30

VI. Board Officers Election .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:50

VII. Consumer -at- Large Election .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11:55

VIII. Strategic Plan Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12:00

IX. Board & Member Job Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12:30

X. AANHPI Access Plan .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1:00

XI. CAHPS Survey .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1:20

XII. CHARN & IRB .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1:40

XIII. Executive Session .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2:00

XIV. Adjourn .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2:30

Curriculum Vitae: Monica Adams

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Address Mailing PO Box 1497 Hilo, HI 96721 Home 17-977 Konomanu Road Kurtistown, HI 96760 Contact Email [email protected] Phone 808-756-2530

Accomplished leader dedicated to working toward the achievement of excellent health care services.

KEY ACHIEVEMENTS

Awarded and managed $15,592,775 in grants for health care services, new construction and renovation projects and programs at the third largest community health center in Hawaii.

16 years of health and human services employment and leadership experience focused on health care administration, strategic planning, fundraising, public relations, budgeting, quality, compliance, human resources, marketing, advocacy and regulatory affairs.

Developed a corporate compliance program for a large, multi-site health center organization. Project director of six Health Resources and Services Administration funded programs. Developed an organizational communications program to address strategic initiatives. Coordinated several multi-year strategic plans.

EDUCATION

Master of Business Administration – Health Care Administration Loma Linda University School of Public Health 2012

Master of Arts – Counseling Psychology University of Hawaii at Hilo 2009

Bachelor of Arts – Psychology San Francisco State University Cum Laude 2005

EMPLOYMENT

Bay Clinic, Inc. Federally Qualified Community Health Centers – Hawaii Island

Director of Development, Compliance and Quality: December 2011 – Present Developed, implemented and managed a comprehensive corporate compliance program, quality

improvement and quality assurance program, and all development, fundraising, marketing and public relations activities. Report to Board of Directors compliance, quality and executive committees and the CEO. Supervisor of eight employees. Performed as acting CEO in CEO absence.

Director of Development and Regulatory Affairs: August 2010 – December 2011 Oversaw all federal, state and local regulatory activities and organization wide development, public

relations and marketing activities. Report to Board of Directors executive committee and the CEO. Supervisor of seven employees.

Director of Development: March 2007 – August 2010 Responsible for all fundraising, grant writing, grant management, budget development and donor activities.

Developed programs, budgets, evaluation plans and proposals for health center activities. Developed and implemented development, marketing, communications and public relations plans. Analyzed and produced needs assessments to determine organizational priorities. Responsible also for the oversight and management of health center programs and compliance with regulatory bodies. Responsible for all federal, state, and local grants and contracts. Supervisor of six employees.

Grant Writer: October 2006 – March 2007 Developed budgets, evaluation plans, proposals and reports for health center activities.

Curriculum Vitae: Monica Adams

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Program Administrator: February 2005 – October 2006 Substance Abuse and Mental Health Services Administration (SAMHSA) grant manager for substance abuse

prevention in Hawaii Island teens. Martin Memorial Medical Center – Stuart, Florida Human Resources Salary Analyst 2001 – 2003 Kelly Services – Baltimore, Maryland Human Resources Representative 1998 – 1999 Red Cliff Ascent – Beryl, Utah Lead Adolescent Counselor 1998 – 2001 TKJ Inc. – Salt Lake City, Utah Home Health Aid 1996 – 1998

COMMUNITY SERVICE EXPERIENCE American Civil Liberties Union Board Member 2012 – Present YWCA Hawaii Island Board Member 2011 – Present Bay Clinic, Inc. Counseling Intern 2007 – 2009 National Council on Alcoholism Bay Area Counseling Intern 2004

FEDERAL GRANT REVIEWER 2011-2012 Health Resources and Services Administration Objective Review Committee Member

RESEARCH ASSISTANTSHIPS 2004 – Adolescent Psychology Department San Francisco State University

2003 – Cognitive and Biological Psychology Department San Francisco State University 2002 – Developmental Psychology Department San Francisco State University

CONFERENCES & PRESENTATIONS 2010 Hawaii Primary Care Association Leadership Series Presenter Title: “Fundraising and Marketing in Community Health Centers” 2010 Hawaii County Healthcare Conference Session Facilitator Title: “Beyond the Physician: Maximizing the Utilization of Midlevel Providers” 2006 University of Hawaii at Hilo – Grant Writing Seminar Presenter

COMMITTEE MEMBERSHIP 2011 Hawaii County Mayoral Healthcare Conference 2011 – Present Hawaii County Health Care Taskforce 2010 – Present Hawaii County Beacon Community Engagement 2010 – Present Hawaii Primary Care Association Development Director Committee Chairperson 2010 – Present YWC Hawaii Island Development and Fundraising Committee 2010 – 2011 YWCA Hawaii Island Finance Committee

CERTIFICATIONS Certified Fundraising Executive – pending exam in 2012 Certified Professional Compliance Officer – pending exam in 2012 American College of Healthcare Executives – fellowship status expected in 2015

CURRENT PROFESSIONAL AFFILIATIONS Hawaii Public Health Association Hawaii Rural Health Association American College of Healthcare Executives Association of Fundraising Professionals

REFERENCES Available upon request

From: Kamahanahokulani Farrar <[email protected]> Date: Tue, Feb 28, 2012 at 9:17 AM Subject: Nomination for a Consumer-at-large representative to AAPCHO's Board of Directors To: Jeffrey Caballero <[email protected]>, Rich Bettini <[email protected]> Cc: Nina Agbayani Grewe <[email protected]> Aloha mai kakou, I would like to be considered for the Consumer-at-large representative to the AAPCHO Board of Directors. I have attached my resume for your review. I am very excited about the opportunity to serve with AAPCHO in the capacity described in the position description. I am able to make the commitment to learn, grow and work hard on behalf of the board and your member organizations. I spoke with Rich Bettini last night at our board meeting about my interest in moving forward to formally submit my name for consideration. Please let me know if this nomination needs to come from the health center CEO and I will ask Rich to re-submit. Mahalo!

-- Kamahanahokulani Farrar

Live, Love, Life!

Notice: This e-mail, including attachments, is covered by the Electronic Communications Privacy Act, 18 U.S.C. §§ 2510-2521, is confidential and may be legally privileged. If you are not the intended recipient, you are hereby notified that any retention, dissemination, distribution, or copying of this communication is strictly prohibited. Please reply to the sender that you have received the message in error, and then delete it. Thank you.

D. Kamahanahokulani Farrar 85-101 Kaulawaha Road Waianae, Hawaii 96792

Email: [email protected] Cell: 808-681-9312

Qualifications Seasoned manager with solid experience in policy, program/project management and community engagement to improve health care delivery and health outcomes. Successfully working with Federal, state and local partners and stakeholders. Over 20 years of experience in operational management, and 10 years in addressing health disparities in innovative ways, with emphasis on community outreach and learning networks (i.e., engaging both providers and consumers in health care transformation). Serve on various boards of directors, identifying and helping implement local and national service opportunities with a focus on community boards, developing collaborations and partnerships, and mentoring stakeholders on “Triple Aim” initiatives and health care reform (i.e., “better care, better health at lower per capita costs).

Policy Experience October 2010 – Current Chair, Accountable Healthcare Alliance of Rural Oahu (ACO) Promoting access, quality, and cost effectiveness in healthcare by empowering consumers to evaluate the performance of healthcare agencies that serve them. Created and operated through an interagency agreement of community health centers in three rural, medically underserved areas. January 1994 - May 1999 Organizational Development Consultant Hein Consulting Group Portland, Oregon Identified and responded to funding opportunities, including developing program and curriculum design as well as project outcomes. Primary areas of training responsibility were cultural diversity and manager training to improve staff retention and decrease exposure to litigation. Expert in focus group facilitation.

Program Management Experience Executive and professional experience focused with building efficient and effective organizational systems and teams, employee and labor relations, all benefits administration, professional training and staff development, recruitment and records management. August 2011 - Current University of Hawaii, JABSOM Department of Native Hawaiian Health Community Engagement Liaison, RMATRIX Grant



The John A. Burns School of Medicine (JABSOM) is one of five U.S. academic institutions funded through the National Institutes of Health's Research Centers in Minority Institutions. That's the "R." MATRIX stands for Multidisciplinary and Translational Research Infrastructure EXpansion. Translational research rapidly transfers research findings to treatment settings to benefit patients. September 2005 to August 2011 Health Service Coordinator, Papa Ola Lokahi 894 Queen Street, Honolulu, Hawaii 96813 Our mission is to improve the health status of Native Hawaiians by increasing the number of culturally competent Native Hawaiian clinicians in eighteen primary health care professions. Primary responsibilities include: Ensure compliance with a HRSA contract with accurate program reporting, monitoring and records management. Provide beneficiaries guidance and support from education through professional licensing and upon entry into employment. Provide the Native Hawaiian Health Care Systems executive directors and management teams with technical support focused on organizational development, capacity building, professional development, and mentoring, customized training development and delivery and change management. Develop local and national community partners in the areas of rural and minority health by providing expertise in education and capacity building, leadership and mentoring, skills development and advocacy. Develop a rural workforce by developing and monitoring internships, residencies and employment collaborations.

April 2009 to July 31, 2010 Associate Director, Na Puùwai, Native Hawaiian Health Care System Post Office Box 130, Kaunakakai, Hawaii 96748 Our mission is to improve the health of people living on Molokaì, Kalaupapa, and Lanaì by providing culturally appropriate education, prevention, wellness, enabling and traditional healing services. Primary responsibilities: Ensure compliance with federal and state employment laws, contracts and grants. Provide support and expertise to the executive director by developing an organizational structure focused on efficient operations and quality administration. Develop leadership capacity, mentoring and training for staff and the Board of Directors.



July 2000 – August 2005 Director of Human Resources, Hale Kipa, Inc. 615 Pi`ikoi, Suite 202, Honolulu, Hawaii 96822 Operations: As the HR Director, I was responsible for the oversight of our recruitment, hiring, transfers and promotions for all internal and external applicants and all benefits administration. With a staff of over 200 employees, I provided job coaching, discipline, performance reviews support for all Program Directors and department supervisors including all terminations. Our strengths included developing and maintaining collaborations throughout the organization, accurate documentation and records management with the development and implementation of the organizations first HRIS. As the HR Director I was responsible for the development and modification of internal policies and procedures, state and federal laws and best practices with our national accreditation. Leadership Responsibilities: Collaborate with other departments and all members of the Leadership Team to implement the vision and long term goals of the agency. Provide on-going support to directors, supervisors, managers and coordinators in the supervision of over 200 staff. Training Responsibilities: Develop successful learning opportunities for all new hires, mid-level managers and other job groups as identified with a focus on skills building, competency, career path goals and community building. June 1989 – December 1993 Personnel Manager, Oregon Relay Service Oregon Deaf Resources Center, Portland, Oregon A new federal law required all states to provide telecommunications service to all citizens. The Oregon Deaf Resources Center offered volunteer operator assisted calls with TDD users for 20 years. The Oregon Relay Service received the first contract to offer speech and hearing impaired telecommunications users access to the telephone system. Hired first as an operator, promoted to lead operator and then to Personnel Manager. As the personnel manager, responsibilities included all human resource functions and training to entry level and supervisory staff. Diverse responsibilities for this start-up included the development and modification training materials and technical manuals. Hired to manage the non-profit Oregon Deaf Resources Center.

Community Engagement Experience August 2011 - Current University of Hawaii, JABSOM



Department of Native Hawaiian Health Community Engagement Liaison Waianae Coast Comprehensive Community Health Center Our mission is to make available to all residents of the Waianae District, complete comprehensive health and related human services. Chair, Board of Directors Current State & National Committee 2007-2008 Strategic Planning Committee 2007-2008 National Association of Community Health Centers (NACHC) The mission of the NACHC is: “To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations.”

National Conference - Workforce Track – Speaker 2009 Health Center Finance Subcommittee 2008 – Current Rural Health Committee 2010 American Public Health Association The American Public Health Association (APHA) is the oldest and most diverse organization of public health professionals in the world. APHA represents a broad array of health professionals and others who care about their own health and the health of their communities.

Conference speaker 2007 and 2008 American Indian, Alaska Native, Native Hawaiian Caucus Program Co-Chair 2008 - Current Association of Asian, Pacific Islanders Community Health Organizations The Association of Asian Pacific Community Health Organizations (AAPCHO) is a national association representing community health organizations is dedicated to advocacy, collaboration and leadership that improves the health status and access of Asian Americans & Native Hawaiians and other Pacific Islanders within the United States, its territories, and freely associated states, primarily through our member community health centers.

Advisory Council Member: 2008 Mentoring Project Member 2010 Conference Speaker 2010 & 2012



Hawaii Primary Care Association (HPCA) The mission of the Hawaii Primary Care Association is to improve the health of communities in need by advocating for, expanding access to, and sustaining high quality care through the statewide network of Community Health Centers.

Strategic Planning Work group, Advisory Council Member: 2008 – 2010 Conference Speaker 2011 Consumer Board Member 2011 Chair, External Advisory Committee 2011

Education Masters of Human Resource Management University of Hawaii - Manoa Honolulu, Hawaii 2002 – 2004 GPA 3.94

Bachelor of Arts Pacific University Forest Grove, Oregon 1976 - 1981 High School Diploma James B. Castle High School Kaneohe, Hawaii 1973 - 1976

Kamahanahokulani Farrar 85-101 Kaulawaha Road Wai`anae, Hawaii 96792

C: 808-681-9312 and E: HYPERLINK "mailto:[email protected]" [email protected]

AAPCHO BOD Meeting Minutes San Diego, CA

Friday, August 25, 2011 Board Members in Attendance: Teresita Batayola (President), Eugene Welch (V. President), Sherry Hirota (Secretary), Jane Eng (Treasurer), Rich Bettini (Immediate Past President), Ben Pettus, May Akamine, Darrin Sato, Hiroshi Nakano, Eddie Lee, Lawrence Lue (via phone) Board Members in Absence: David Derauf, Kazue Shibata Guest in Attendance: Eric Tiberi, Grace Wong Staff in Attendance: Jeff Caballero, Nina Agbayani, Stacy Lavilla, Rosy Chang-‐Weir, Peter Ho, Corinna Dan, Jacqueline Barin, June Kim Welcome & Introductions (TB) New BOD Member vote: Darrin Sato approved to represent KPHC; 10-‐0. ED Report (JC)

• Caballero presented ED Report. • Call for volunteers for ad hoc committees-‐ to clarify AAPCHO’s role in

helping resolve challenges related to integrated health and relationships with AIDS Service Organizations (ASO).

AAPCHO 2012 Proposed Budget (PH) • Ho presented fy 12 budget; • Required additional funds to balance budget with a new policy staff in DC; • 25th anniversary budget-‐-‐$180,000 income; $150,000 from OMH, remaining

balance in expected from fundraising; • BOD request new balance budget proposal with prioritized DC staff; • Also discussed a plan b, to hire lobbyist rather than employee; • Office space is already available at NACHC; presence in DC is vital; • Board consensus that staff in DC is priority; • Revised budget in two weeks sent electronically; • Call for volunteers to help Treasurer (Jane Eng) to review revised budget

(Paul and Eugene); • Plan to vote on new balance budget by mid-‐September.

Proposed Membership Dues Forgiveness Policy

• Waiver policy to balance need to get dues; • Options to waive AAPCHO dues depends on action decided by EC or BOD • Sponsorship-‐ membership dues paid for due to financial difficulty, pay in

next period;

AAPCHO 2011 August BOD Minutes

Page -‐ 2

• Reduction-‐ 25%, 50%, 75% • Waiver – dues not collected for that CHC; • Determination process – EC or BOD to make decision which method to use; • If CHC does not choose option nor pay; membership suspended; including

voting rights suspended; • Reports to EC to keep BOD updated, timeline undetermined; PH will work

with treasurer; • $45,000 outstanding dues to date; • Prior no process to notify BOD of lateness of dues; first step is to have policy

process; there are other ways to cover dues; • Motion to adopt proposed deferment, reduction, and waiver policy with

suspension of membership and Board voting rights with any outstanding dues or any requests for more than a year.

MUA Policy Update (Sherry Hirota) • Scheduled to complete recommendations by October; • Provider to population ratio about 25%, health status is another 25%, and

under health status will be standardized mortality rate, LBR; • Barriers: 4-‐5 factors including LEP, travel time/density measuring ratio

ethnic, disability, uninsured, picked two top factors impact geographic area; • Ability to pay (uninsured, poverty) • Simplify barriers, proposal to switch 4 barriers (LEP, minority, travel density,

switch to uninsured); • Core of committee support the barriers; • Base on uninsured than poverty levels – disincentive; NACHC reconsidered; • Physician to population ratio, do not have to count CHC own physicians; • If there is a change there will be a call for action to address the barriers

ACO Workgroup update

• AAPCHO’s is committed to optimize quality and demonstrating savings for our primary care model, recognition of ES, and consumer engagement;

• AAPCHO ACO committee – the short-‐term goal is to conduct advocacy work. The long-‐term goal is to develop payment reform models which streghten FQHCs, and to share our policy analyses with members;

• Safety net ACO – Promoting release of a payment reform demonstration model with Medicaid at its core;

• 2 issues: ACOS – 1) uncertainty of the impact of alternative payments mechanism on safety net / health centers and ; 2) lack of safety-‐net research / demonstration capability – how can health centers demonstrate / prove their value in new model?

CHARN update

AAPCHO 2011 August BOD Minutes

Page -‐ 3

• Key activities—3 year ARA grant, strengthen CHC research capacity to demonstrate value through partnerships with 3 other networks with a national total of 60 CHCs.

• Identify which CHCs will be involved with CHARN—level of research and capacity building (PCOR)

• CHARN is part of long-‐term strategy to place the AAPCHO network in better position to evaluate services and make decisions best for health centers and our communities;

• Outcomes of CHARN: PCOR capacity for CHCs, responding to research needed to justify services needed at health centers;

• Does not specifically relate to ACOs, however it can be a critical AAPCHO tool to advocate for more equitable shared savings within new networks;

• Research capacity – PCORI provides source of diversifying funding; research grants (non federal sources)

AAPCHO 25th Anniversary March 19th and 20th, 2011

• Preliminary plans will include the leadership game and gala; OMNI in DC; incoordination with NACHC;

• Fundraising goal increase 10-‐25% from 2010 event; committees have been developed and BOD are invited to participate;

• Developing a video contest – please identify a contact person per each member CHC to coordinate staff efforts with.

Executive Session – staff excused Meeting Adjourned

ASSOCIATION OF ASIAN PACIFIC COMMUNITY HEALTH ORGANIZATIONS Executive Director’s Report

September 2011 Please note: report is structure to highlight monthly updates per strategic plan priority areas. Strategic Priority Area 1 – AAPI Special Health Needs No update Strategic Priority Area 2 – Economic Crisis FY13 Appropriations – NACHC & AAPCHO met with White House Budget office regarding FY13 budget; the President is not planning to fund Health Centers at the levels needed to fully meet ACA implementation plan. NACHC is developing a strategy to change the White House’s position. AAPCHO committed to assist with White House and Congressional outreach. We have until February to implement strategy and get the White House back on course to restore expansion plans.

Budget Super Committee - AAPCHO is assisting NACHC secure a support letter from the Congressional Quad-caucus, which include all 3 minority caucuses and the Progressive Caucus (45% of all House democrats) to exempt any budget cuts from the health center program.

Strategic Priority Area 3 – HIT & Research CHARN Research Network– At the August HRSA CHARN meeting with all 5 HRSA network grantees, AAPCHO’s enabling services proposal received the most votes as a priority focus for cross network collaboration. This means other research networks will partner with AAPCHO. Currently, we have learned that 3 other networks may already have similar definitions, but a validation study is being developed to ensure adequate scientific rigor. A 2 page factsheet describing the HRSA CHARN Network is attached. NACHC Meaningful Use Readiness Survey – AAPCHO has collaborated with NACHC to develop the Meaningful Use Readiness survey and the Research Capacity survey. We are encouraging all AAPCHO members to participate. The collaboration was established to reduce the number of survey members have to respond to, as well as, ensuring comparability between NACHC and AAPCHO future research and TA efforts. For future reference, all submitted surveys must indicate, “it is OK to share

Sept. 2011 ED Report Page - 2

with AAPCHO”. NACHC’s survey announcement is attached for more information. Please note, many AAPCHO members have still not responded. AAPCHO staff will be sending a follow-up reminder to our members encouraging their participation. Participation will ensure adequate needs, priorities, and resources are accounted for in planning and development efforts. NACHC National Data Warehouse Strategy – NACHC is looking into developing a national data warehouse by merging HCCN regional data repositories. NACHC is also looking at AAPCHO, due to our PIC & CHARN data experience, to advice their efforts. NEW Part-Time HIT Programmer – AAPCHO staff collaborated with members to hire a half-time AAPCHO HIT Programmer to provide member support services. This new staff will make it possible for more members to participate in AAPCHO’s HIT and data warehousing activities. CPCA PCMH and Enabling Services Study – CPCA study from 46 CHCs found that all would be NCQA recognize at a advance level with only minor modifications. However, CPCA’s study found no association between NCQA PCMH performance and diabetes quality outcomes. As AAPCHO has demonstrated, they are now asserting enabling services and community engagement elements are needed by NCQA standards to associate diabetes care quality in MUA/P. AAPCHO will continue to collaborate with CPCA & UCLA to validate their assertion by conducting a follow-up survey incorporating ES data.

Strategic Priority Area 4 - Strengthening AAPCHO & Members Board & Membership Engagement Plan – As proposed in August Board reports, a preliminary Board & Membership Engagement plan has been initiated. Additionally, a Consumer Leadership Engagement plan is being developed as a result of the San Diego Consumer Leadership Conference meetings convened by AAPCHO’s Consumer At-Large Board member, Hiroshi Nakano. Consumer Leadership Game – As discussed in San Diego, select Board members and staff have began preliminary planning for the integration of the Consumer Leadership Game into AAPCHO’s 25th Anniversary Conference in March 2012. On-going planning and next steps will be clarified with the respective conference planning committee.

Sept. 2011 ED Report Page - 3

Strategic Priority Area 5 - Workforce BPHC Competitive Training/TA Grant – The BPHC national training/technical assistance grant was awarded with a $100 thousand increase from last year’s funding level. However, until the 600 million cut in HRSA budget in April 2011, we were anticipating a $200 thousand increase as proposed. Currently, we are negotiating with BPHC to adjust the scope of work.


October 2011 Please note: report structure highlights monthly updates as per respective strategic plan priority areas. Strategic Priority Area 1 – AAPI Special Health Needs Implementation of the National Viral Hepatitis Plan - HHS Deputy Assistant Secretary Dr. Ron Valdesseri, has recruited AAPCHO Hepatitis B Fellow, Corinna Dan to coordinate implementation of the national Viral Hepatitis Elimination Plan. Corinna will be leaving AAPCHO Nov. 1st. A transition plan for completing the last 5 months of the Hepatitis Fellowship deliverables is in development. NCQA Releases PCMH Patient Engagement Measures/Criteria – Because consumer/patient experience is a critical component of quality care, recognizing more prominence to patient engagement in a PCMH program. NCQA developed an optional distinction in patient experience reporting to help capture patient and family feedback through a newly developed Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey. Strategic Priority Area 2 – Economic Crisis FY13 Appropriations – I am meeting with NACHC Federal Affairs staff to be briefed on the White House advocacy agenda to restore FY13 President’s projected budget on October 18th.

Budget Super Committee - AAPCHO assisted NACHC secure a support letter from the Congressional Quad-caucus, which include all 3 minority caucuses and the Progressive Caucus (45% of all House democrats) to exempt any budget cuts from the health center program.

AAPCHO is also partnering with NACHC Grassroot Advocacy staff to conduct a AANHPI language post-card campaign to promote LEP consumer leadership participation in national advocacy efforts to save Medicaid & health center funding. Post-card templates in 4 Asian languages & English are available from the AAPCHO website for download. A partnership with health centers with predominantly Spanish speaking consumers is also being pursued.

Oct. 2011 ED Report Page - 2

Strategic Priority Area 3 – HIT & Research CPCA PCMH and Enabling Services Study – AAPCHO has started to collaborate with CPCA and UCLA to conduct a follow-up survey with CPCA members.

OMH Director Dr. Garth Graham Resigns – Dr. Graham on September 30 announced his intention to resign from OMH beginning Nov. 1st to help take care of his ill parents. Dr. Howard Koh announced that Dr. Nadine Gracia will be serving as Acting Director of OMH. Dr. Graham and Dr. Gracia will be meeting with me on Oct. 21st to develop a transition plan between OMH and AAPCHO and ensure continuation of our successful relationship.

Strategic Priority Area 4 - Strengthening AAPCHO & Members Board & Membership Engagement Plan – No updates since last month. Consumer Leadership Advocacy – As noted in SPA 2 above, AAPCHO is engaging member consumers with a postcard advocacy campaign to encourage participation of LEP consumers in national advocacy efforts to save Medicaid and health center funding. The staff effort is being led by Consumer-Atlarge Board Member Hiroshi Nakano and NACHC Chair Kauila Clark. Consumer Leadership Game – As a follow-up to San Diego discussions with CMS representative Rob Tagalicod; I will be meeting with CMS’ new Interim OMH Director, Renard Murray, regarding potential partnerships between AAPCHO and CMS related to ACA implementation and patient / community engagement. NAP Learning Team – As approved by the Board, AAPCHO worked with 9 local AA&NHPI organizations to prepare NAP applications. Of the 9, 7 completed and submitted NAP applications. As previously reported, no one was funded due to application of Special Population criteria which our applicants were not eligible. One of the applicants we assisted, from Ohio did receive a planning grant. Thus far, we are aware the scores ranged from 98 -87.

Oct. 2011 ED Report Page - 3

AAPCHO is working with learning teams and NACHC to develop an advocacy strategy for all the competitive but unfunded NAP applications. We plan to continue working closely with the AAPI White House Initiative Office to advance advocacy for our learning teams and the AA&NHPI communities they serve. Strategic Priority Area 5 - Workforce BPHC Competitive Training/TA Grant – As required by new BPHC national cooperative agreement, AAPCHO is partnering with the National Association of Community Health Centers (NACHC), National Health Care for the Homeless Council (NHCHC), Migrant Health Promotion, and Health Outreach Partners (HOP)) to develop and disseminate a National Outreach Guideline for Underserved Populations. We are building off of HOP's current Farmworker Outreach Program Guidelines that were developed approximately 10 years ago. The vision is to develop guidelines that are relevant to a larger medical home discussion for underserved populations, and to jumpstart much needed conversations around bringing standardized, effective, and community-based outreach practices to our populations. AAPCHO needs to identify and recruit 5 member representatives to Serve as "advisors" to comment on and ultimately approve the definitions, concepts and guidelines to be be developed. A broad mix of perspectives, including CHC staff knowledgable about eligibility/outreach and consumers/consumer BOD members is requested.


November 2011 Please note: report structure highlights monthly updates as per respective strategic plan priority areas. Strategic Priority Area 1 – AAPI Special Health Needs NRM Committee Preliminary Report – Because the NRM Committee was not able to reach consensus at the final September meeting, a preliminary report has been developed for HHS review. As anticipated, Sherry was able to help secure LEP as an option in the needs formula. Secretary Sebelius is anticipated to release final report in January/February 2012. AAPCHO is working closely with the White House and HHS to ensure LEP criteria is not eliminated from final consideration. Gilead Foundation’s Hepatitis Policy Fellowship – As noted last month, AAPCHO’s Washington DC Hepatitis Policy Fellow position is currently vacant. 5 months remain on the 3 year award from the Gilead Foundation. Currently, the Foundation is re-evaluating if this unsolicited award will be renewed. Strategic Priority Area 2 – Economic Crisis FY13 Appropriations – AAPCHO and NACHC staff has a meeting pending with Chris Lu, President Obama’s Cabinet Secretary and Co-chair of the White House AAPI Initiative. As requested, Chris Lu is the highest ranking White House official accessible to meet with us to restore the President’s FY13 Health Center Budget.

Additionally, another 2000 postcards now totaling about 7000 postcards from AAPCHO members have been sent to President Obama asking him not to cut health center and Medicaid budgets in multiple Asian languages and English.

Budget Super Committee - AAPCHO efforts to outreach to Budget Super committee continues. In addition to the Congressional Quad-caucus support letter, another letter from all 28 members of the National Council of Asian Pacific Associations which includes all existing national AAPI organizations asked not to cut health centers and the Medicaid program.

Nov. 2011 ED Report Page - 2

Strategic Priority Area 3 – HIT & Research New OMH Director Nadine Gracia Affirms Commitment to AAPCHO – On Oct. 21st, I met with both Dr. Nadine Gracia and Dr. Graham to revisit OMH funding commitments to AAPCHO. Pleasantly candid, Dr. Gracia re-affirmed OMH’s commitment to continue support for AAPCHO’s 25th Anniversary event and on-going health reform implementation efforts.

Strategic Priority Area 4 - Strengthening AAPCHO & Members Board & Membership Engagement Plan – After a brief break, Hiroshi and Larry renewed membership committee efforts to develop Board and member roles description as proposed in August Board meeting. Consumer Leadership Engagement – As previously reported, a meeting to pursue opportunities between AAPCHO and CMS’ Office of Public Engagement and Innovations Center is planned for December. Additional meetings are anticipated in January in coordination with NACHC Winter Retreat in preparation for March 25th Anniversary event. Strategic Priority Area 5 - Workforce No updates in this area.


January 2012 Please note: report structure highlights monthly updates as per respective strategic plan priority areas. Strategic Priority Area 1 – AAPI Special Health Needs NRM Committee Preliminary Report – Due to AAPCHO’s requests, the WHIAAPI convened a meeting with HHS Policy Office to get a briefing on the status of the NRM Preliminary Report. The WHIAAPI adopted AAPCHO’s position of ensuring the inclusion of LEP in the proposed formulas. Based on the HHS Policy Office, they foresee the Secretary will be posting the NRM Preliminary Report as submitted. They are not sure when the rule will be posted on Federal Register. HHS will notify WHIAAPI if there are any new developments. 2012 Hepatitis B Initiatives – Over the last couple of months, AAPCHO has been involved in planning to identify 2012 hepatitis B priorities. Based on discussions with partners and funders, AAPCHO will be involved in following hepatitis B priority areas: 1) advocating for national policy that will help ensure CHCs have adequate resources to provide evidence-based screening, vaccination, and treatment resources for the at-risks population served; 2) assisting federal and local hepatitis coalitions partner to implement the national hepatitis action plan; 3) secure funding for local partners (specifically member organizations) and community awareness efforts. Strategic Priority Area 2 – Economic Crisis FY13 Appropriations – As requested by NACHC, AAPCHO secured a meeting with Chris Lu, White House Cabinet Secretary and Co-Chair of the White House AAPI Initiative. On Dec. 12th, AAPCHO represented by Teresita Batayola and Jeff Caballero, and NACHC represented by Dan Hawkins & Craig Kennedy met at the White House with Chris Lu, Thomas Lue, Deputy General Counsel for the Office of Management & Budget, Christina Lagdameo, Deputy Director of the WHIAAPI, Eddie Lee, Associate Director of the White House Office of Public Engagement. We discussed the need for more White House leadership in ensuring CHCs budget in the FY13 President Budget is not reduce any further or else jeopardize the hundreds of new and expansion clinics, new jobs, economic development, and ribbon-cutting ceremonies throughout the country in 2012. As an example, Teresita describe the hiring which did not occur at her clinic because of the 2011 budget cut. In addition, we spent some time

Jan. 2012 ED Report Page - 2

discussing the 8 new access points which were not funded because of the 2011 budget cuts. Though no commitment was secured, they noted the President supports our concerns and will follow-up if needed. Additionally, they also requested we continue to work with HRSA/BPHC to better collect and report AA and NHOPI population being served. Pilot AAPI Multi-lingual Post-card Project – Approximately 6 member centers participated in AAPCHO’s project to engage CHC patients in this budget advocacy project. Approximately11,000 postcards were sent or hand-delivered to the White House asking to protect the CHC and Medicaid budget. A preliminary analysis identified a number of potential improvements, but overall, we need to get more membership involvement in our efforts to represent our patient community. It is important to note however the White House and NACHC did recognize our effort for the diverse community we serve, by acknowledging our effort in a NACHC video blog. Strategic Priority Area 3 – HIT & Research AAPCHO CHARN Research Project – The Community Health Applied Research Network that AAPCHO participates in will be meeting in NYC and Washington, DC between Jan. 30- Feb.2nd. CHARN will be meeting with national network and key policy makers and funders trying to secure new funding and research opportunities. The Commonwealth Fund – TCF is developing a new initiative focusing on enabling services for vulnerable populations. TCF is starting the initiative with an Advisory Committee, which includes a number of national representatives involved in the study of enabling services. AAPCHO’s Rosy Chang-Weir has been invited as a member of the initiative’s advisory committee. In addition, AAPCHO has requested and already convened a call briefing TCF’s project officer, Dr. Pamela Riley, on all our efforts and existing initiatives. CMS Innovation Center – I have requested a Feb. 2nd or 3rd meeting with CMS Innovation Center and CMS Office of Public Engagement leadership to solicit support for AAPCHO members patient centered / patient engagement initiatives. The February meeting is a follow-up to the meeting staff conducted with CMS Office of Minority Health and Rob Tagalicod’s office to secure internal support.

Jan. 2012 ED Report Page - 3

Strategic Priority Area 4 - Strengthening AAPCHO & Members Board & Membership Engagement Plan – this small but productive committee has developed preliminary recommendations for enhancing Board and member engagement through the clarification of roles and committee structures for organization-wide policy and decision-making. The preliminary recommendations will be presented to Executive Committee in January 2012 meeting and the Board in March 2012 meeting. An additional document to better clarify the consumer-at-large role is still in development and will be submitted at a later time. 25th Anniversary Conference & Gala – Fundraising, outreach, and registration has been initiated for the March 19-20th event. Several staff members have also initiated direct personal campaigns to raise funds for AAPCHO in addition to the traditional organizational outreach. Staff will provide another status update during the Executive Committee January conference call. Strategic Priority Area 5 – Workforce Clinical Leadership Listserv - Several member medical directors and chief medical officers has requested AAPCHO develop a on-line listserv to facilitate discussions and peer support between members’ clinical leadership. Currently, approximately 6 clinicians from 6 sites in four states are engaged in discussions about meaningful use implementation with their clinicians.


February 2012 Please note: report structure highlights monthly updates as per respective strategic plan priority areas. Strategic Priority Area 1 – AAPI Special Health Needs Gilead Foundation’s Hepatitis Policy Fellowship – A new proposal for another 3 year Advocacy Fellowship has been submitted to the Gilead Foundation. The focus of the proposal is less legislative and more administrative advocacy oriented. When awarded, I anticipate a 2-month search and recruitment period, then the new Advocacy Fellow will be housed in the second office space sub-leased from NACHC. National Hepatitis B Awareness Campaign – AAPCHO is partnering with the Center of Disease Control (CDC) and the Hepatitis B Foundation to develop a national awareness campaign, which will award grants to local coalitions aiming to educate and screen AANHPI communities at-risks for hepatitis B in fy13. FQHCs & AIDS Service Organizations (ASO) – To relieve growing national tension because of ASOs advocacy efforts to become FQHCs, AAPCHO is assisting APIAHF increase ASOs serving primarily AANHPIs understanding of all their options for improving access to primary care services for their patients. APIAHF is currently looking for resources to conduct webinars and secure consultants to conduct the training. Diabetes Prevention & Social Determinants of Health – Staff involved in an AAPCHO CDC demonstration grant are preparing for a meeting in Hawaii in May which convenes the regional diabetes and CBO partners and the 3 member grantees: APHCV from LA, Waimanalo from HI, and Kuajelan Health Center from the Marshall Islands. CLAS Enhanced Standards – As some of you know, AAPCHO has been participating as an advisor to the development of the new Enhance Culturally & Linguistically Appropriate Services Standards over the last year. Last Friday, HHS has cleared the release of the new proposed standards. We had been hoping for a March release target date which can concur with our 25th Anniversary, but recent news indicates that it may await until Minority Health Month, April. A near final version of the new standards are available from AAPCHO by request.

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Strategic Priority Area 2 – Economic Crisis Navigating CMS – Over the last month, I have utilized federal relationships to develop and strengthen relationships in CMS. Specifically, I have reached out to CMS’ New Acting Office of Minority Reynard Murray; Marsha Lillie-Blanton, Senior Policy Advisor at Office of Quality Improvement; Susie Butler, Director of CMS’ Office of Strategic Partnerships; and Anne Avery, AAPI Liaison at CMS’ Office of Public Engagement. On February 28th, I will be meeting with Jim Hester, Senior Advisor to the Director of CMS’ Center for Medicare & Medicaid Innovations’ Dr. Gilfillan. The intent is to establish an on-going relationship with CMS similar to OS/Office of Minority Health, which would support AAPCHO Medicaid advocacy, demonstrations, and research efforts.

At the Feb. 28th meeting, I am looking to cultivate interest in AAPCHO members’ capacity to participate in demonstration projects and requesting a meeting on behalf of Waianae, Waimanalo, and Ko’olauloa to promote the AHARO virtual ACO model.

President’s FY13 Budget Request – The recently released White House Budget requests includes both of AAPCHO’s requested items from our meetings with OMB and the White House. First, we avoided the HRSA CHC budget cut which was anticipated last Summer, and secondly, CDC Division of Viral Hepatitis received the 10 million increase for a hepatitis education and screening campaign. Unfortunately, the Office of Minority Health (OS) was cut 16% total, including a 17% cut in the national cooperative agreement line item. We did not advocate for the Office of Minority Health because we were in the understanding from the Congressional Tri-Caucus that OMH budget was not at-risks of cuts. Strategic Priority Area 3 – HIT & Research Community Health Applied Research Network (CHARN) – HRSA’s patient centered outcomes research network is in the second year of a three year funding cycle, and is now beginning to develop sustainability plans. The AAPCHO node of CHARN recently had a meeting to evaluate our current progress and develop new strategies. The 3 key findings of the evaluations are 1) the AAPCHO node plays a critical leadership role in all of CHARN to advocate for a research infrastructure that considers CHC equal partners and inclusion of consumer engagement; 2) CHARN as a large network is too slow and resistant to AAPCHO’s community-based research model and


agenda; and 3) AAPCHO’s academic partner NYU is an inadequate partner for this important effort. Our next steps is to 1) replace current academic partner, 2) develop two parallel sustainability plans: a) continue exploring partnerships with CHARN network while also b) developing plans for our network without CHARN.

IRB Development – To further strengthen and enforce research consistent with AAPCHO values & principles, AAPCHO CHARN members and research partners highly recommend AAPCHO develop an IRB (Institutional Review Board). The challenge primarily is supporting a dedicated position to mange IRB logistics, and recruiting a sustainable pool of volunteers from member and partner organizations. HHS HIT Disparities Report – In 2011, HHS conducted an investigation in how HIT is being used to reduce health disparities, a Congressionally mandate investigation. A recent draft of the report was released which features AAPCHO’s Enabling Services activities and four member centers (ICHS, CBWCHC, WCCHC, & KPHC) as a case study of how HIT is being utilized effectively, particularly in the AANHPI community. A final version of the report is anticipated prior to our 25th Anniversary event, but may be delayed until Minority Health Month, April. Strategic Priority Area 4 - Strengthening AAPCHO & Members WHIAAPI / HRSA Meeting – As follow-up to AAPCHO/NACHC meeting with the White House, a meeting with HRSA to request more data and information on how the FQHC expansion budget can better serve AANHPI communities was convened on February 1st. In the meeting, we learned that HRSA is willing to share data and information collected from the 200+ NAP applications submitted in 2011, including information from the 67 NAP new grantees. My recommendation is to turn this dialogue and commitment to partner with AAPCHO and WHIAAPI into an opportunity to assist HRSA develops and implement a plan for ensuring adequate increases of new AANHPIs served over the next 3 years through both expansions of existing sites and NAPs. Staff Review of Strategic Plan – Over the last 3 months, staff has been regularly evaluating all activities, progress, and resources devoted to strategic plan. A summary report including our findings, updated projections, and recommendations are being developed. We have also developed a quarterly plan to track and evaluate our progress through 2012.


25th Anniversary Conference – Our conference examines and features the critical role of patient & community engagement in the transformation of health care services. We are in the final stages of recruiting speakers representing AAPCHO consumer leadership, member staff, and other national leaders involved in transforming health care delivery. More agenda details are regularly updated at the conference website: ctow.aapcho.org. We have just secured Yul Kwon once again to serve as master of ceremony for the gala. We have also secured Dr. Anne Beal, Chief Operating Officer for the Patient Centered Outcomes Research Institute (PCORI), which just received a 78 million increase in the President’s FY13 Budget. Other celebrities serving as plenary speakers include: Kauila Clark and Dan Hawkins. We are also in discussions with Chris Lu, White House Cabinet Secretary and Co-Chair for the WHIAAPI to make opening remarks at the conference. We will know by next week if Chris Lu will be secured. Strategic Priority Area 5 - Workforce No updates in this area.

AAPCHO Board of Directors Report

Report Topic: 2012 Strategic Plan Update Submitted by: Jeff Caballero Board of Directors Meeting Date: March 21, 2012 Background: AAPCHO conducted an organization-‐wide assessment of available resources and current activities that support Strategic Plan goals and objectives. Our process included a SWOT analysis of each objective and consequent prioritization of all objectives and activities. Besides identifying priority areas and developing a 2012 workplan, the exercises helped identify gaps and needs to strengthen each objective. The review process also helped improve staff understanding of the strategic plan and clarified the role they can play to ensure its success. An attachment to this report, details by objective activities and a summary status statement. Additionally, we are developing an on-‐line dashboard that will help us monitor our progress towards our goals, and we also established a quarterly schedule to evaluate our progress and to adjust our plans as necessary. General findings from staff 2012 SP analysis:

1) Current environment more conducive to advance administrative activities & strategies than legislative activities with the exception of budget/appropriations activities;

2) Prioritize ACA implementation opportunities which cannot be repealed (HIT integration, payment reform, CHC growth, PCOR, Disparities, & PCMH development);

3) Success is more likely in areas with engaged members; 4) Continue to build on vital CHC & community research infrastructure; 5) Build on staff capacity /development in priority areas; 6) Secure additional resources and partners to better position AAPCHO in 2013 post-‐

election period. Based on these general findings, we recommend the following priority objectives in 2012: (obj. 1,2, 3,6,7, 8,10, & 11). Prioritized activities will be our focus with existing resources in 2012. Non-‐prioritized activities may still be conducted if they are part of an existing, funded program, do not compete with resources needed for priority areas, or if additional funding are secured. An updated strategic plan with revised 2012 measures will be submitted to the Executive Committee for approval. Action Requested: Approve 2012 Strategic Plan recommendations

AAPCHO Strategic Plan StatusAs of 3/8/12

Objective Activity Benchmark/Status1.1 In language material review standardsin collaboration with ADA

Year 1: MOA signed with ADA; Year 2: Draft standards developed in accordance with CLASstandards, by 5/2012, 5% completed.

1.2 Health Outreach Guidelines Outreach guidelines developed by June 2012 with no fewer than 4 AAPCHO partnersinvolved in review panel, by 5/2012, 5% completed.

1.3 TA Conferences Conference convened in 2012 and 2014, by Biannual, 10% completed.

1.4 Consumer Leadership Development Incorporate consumer leadership development in 2012 Conference; Support WCCHCconsumer conferences in 2013 and 2014, by December 2014, 10% completed.

1.5 Health Disparities/Access promotion 3 webinars/podcasts per year focusing on health disparities, by Ongoing, 15% completed.

1.6 Facilitate interpretation best practicelearning team

Three interpretation best practices learning team calls conducted each year, by Decmber2014, 10% completed.

1.7 Health Center Social DeterminantModel

promotion of 1.5 and integration of PCMH model with specific focus on health disparity; 2webinars per year, by ongoing, 0% completed.

1.8 Partner with NACHC and PCA onemergency management projects

Participate in monthly calls. Collaborate with NACHC/PCA in responding to emergencies asneeded, by December 2014, 10% completed.

1. By 2014, 60% (14) ofAAPCHO membercommunity health centerswill have received AAPCHOTA support to adopt andintegrate a CHC -

‐ PCMH

model to address the specialhealth needs (healthdisparities, socio economicstatus, cultural and linguisticbarriers, immigrants) of theAA&NHOPI populationsserved.

Confidential - Draft 3/8/2012 Page 1


Objective Activity Benchmark/Status2.1 AADE/ADA/NDEP/NVHR/TaskforcePartnership

AADE (NA): Participate in quarterly leadership calls, 1 F2F leadership forum and 1 annualF2F meeting annually. ADA (NA): Participate in monthly calls & 2 F2F meetings annually,by NA: AADE & ADA: 12/12, 2% completed.

2.2 Implement CDC Diabetes Program Establishment of 3 local coalitions, development of 3 social/environmental changeinterventions, by 8/2016, 20% completed.

2.3 Planning of Hep B United 5 new partnerships developed per year, by 8/30/2012, 50% completed.

2.4 CDC - Diabetes: Coalition Building,Systems Change, SDOH

Provided project sites with evidence based strategies to implement systems changeapproaches, by 2015, 20% completed.

2.5 Hep B: Strengthening the Hep BNetwork

1 annual face to face meeting per year, by 2012, 5% completed.

2.6 NYU CEED: Provider training pilot test Promotion of providing training 2 times a year after pilot has been conducted and sharedwith other member centers, by 2012, 10% completed.

2.7 Gilead Hep B Project:Policy change &resource creation

Advocacy to increase support for screening, education, vaccination, and treatmentservices., by 2013, 10% completed.

2.8 Describe CLAS PCMH Model Advocacy for policy change to find funding for CLAS related services., by 2014, 10%2.9 Evaluate PIC Decision tool inimproving Diabetes care

Summer 2012: Create PIC ES evaluation report publication, by 9/30/2012, 30% completed.

2.10 Asthma (ACU): Promotion of AsthmaResources/provider training

ACU exhibit at our conference. AA&NHOPI Asthma materials identified by 8/31/12, by2012, 5% completed.

2. By 2014, staff will haveidentified, developed, andpromoted at least 4-5innovative and sustainableCHC strategies thatcontribute to high valueresults related to Hepatitis B,Diabetes, CLAS Standardsand Immigrant health needsof medically underservedAA&NHOPIs.



Objective Activity Benchmark/Status3.1 Develop an ACA advocacy strategy 20% (2 members) increase per year, by 2014, 0% completed.

Objective Activity Benchmark

4.1 CoFA (Compact of Free Association)Migrant Advocacy

Not prioritize in 2012, by 2014, 0% completed.

3. By 2014, develop andimplement an advocacystrategy to preserve fundingand adequatereimbursement for servingAA&NHOPI population whichengage 75% (10) ofAAPCHO's Board ofDirectors and increasing theengagement of AAPCHO'smembership 100% from2011 Baseline.

4. By 2014, develop andimplement an advocacystrategy in partnership withother national advocacyorganizations/coalitions tohelp eliminate 5 year bar forimmigrants, as well aspromote inclusion of COFAmigrants for Medicaideligibility which will engage atleast 3 of AAPCHO's Boardof Directors and increase theengagement of AAPCHO'smembership 100% from2011 baseline.



Objective Activity Benchmark/Status5.1 AAPCHO PCMH& MU learning teams;Communications plan to promoteawareness of PCMH & MU; 2 new PCMH& MU grants; fact sheets/webinar/toolkit

Engage at least 70% of EMR members who indicate they are interested in receiving TA, by12/2014, 5% completed.

Objective Activity Benchmark/Status

6 AAPCHO enabling services nationaldata collection

ES data collection TA provided to up to 75% (16) of member CHCs who commit interest, by12/2014, 25% completed.

5. By 2014, staff will developand implement a plan toengage at least 70% ofAAPCHO members withEMR to build expertise in MUand PCMH.

6. By 2014, expandAAPCHO Enabling ServicesData Collection to at least75% (16) of AAPCHOmember community healthcenters, and supportpartnerships with NACHC,Homeless HC, & MigrantsHC to assist another 50-

‐100 community health

centers collect enablingservices data.



Objective Activity Benchmark/Status7.1 Secure 1 PCOR grant; Online PCORresource center (online database); PCORlearning teams

Increase engagement of at least 2 additional AAPCHO CHCs starting with baseline of 3CHCs, by 12/2014, 20% completed.


8.1 25th Anniversary Fundraising Increase donations/sponsorships by 10% (compared to 2010 efforts), by 3/2012, 15%completed.

8.2 Secure new federal/foundation grants Increase funding by 20%, by 12/2014, 10% completed.

8.3 Sustain/Expand PIC: includingpartnering with PCAs

Spring 2012: Brainstorm ideas with partners at face-to-face meeting, by 5/31/2012, 25%completed.

8.4 Explore revenue source through PIC Spring 2012: Brainstorm ideas with partners at face-to-face meeting, by 12/31/2012, 1%completed.

8.5 Optimize cash flow/budgetmanagement

12 successful monthly close outs, indirect rate within 1% of target, by 6/30/2012, 1%completed.

8.6 Explore cost savings options Identify 4-6 expenditure areas that can generate cost savings, by 9/30/2012, 0% completed.

8.7 Monetize existing activites Identify 2-3 partners or funders, by 2014, 0% completed.8.8 Explore new revenue sources Identify 2-3 new revenue sources, by 2014, 10% completed.

7. By 2014, staff will developand implement a plan toengage at least 25% (5) ofAAPCHO member healthcenters to build expertise inPatient Centered OutcomesResearch (PCOR) andconduct at least one PCORstudy.

8. By 2014, increaseorganizational funding by20% through thedevelopment andimplementation of a 3-

‐year

business plan.




9.1 Develop new member center N/A, by 12/31/2012, 0% completed.9.2 Develop communication protocol N/A, by 12/31/2012, 0% completed.9.3 Develop BOD/Member Job Job descriptions finalized, by 8/2012, 25% completed.9.4 Creating communications vehicle for N/A, by 3/2012, 5% completed.9.5 Membership Engagement Best N/A, by 3/2012, 5% completed.9.6 Create membership database N/A, by 3/2012, 5% completed.

Objective Activity Benchmark10.1 To update MUAC datasets tointegrate 2010 Census data and identifyAA&NHOPI medically underserved priorityareas

Updated MUAC fact sheet that includes new 2010 Census data by 2013, by 12/2014, 0%completed.

10.2 Provide TA to potential FQHCs/newmembers

Support at least 5 New Access Point applications per year in 2012-2014 (subject to changeas dependent on funding levels for NAP and HRSA), by 12/2014, 10% completed.

10.3 Clarify AAPCHO TA Priorities/Role:including PI

N/A, by , 0% completed.

9. By 2014, increasemembership involvement by25% each year through thedevelopment andimplementation of a Board ofDirectors & membershipengagement plan.

10. By 2014, expandmembership by at least 3FQHCs/look-

‐a-

‐likes

committed to AAPCHOGuiding Principles andValues over the next 3 years.



Objective Activity Benchmark/Status11.1 To increase staff knowledge inAAPCHO strategic priority areas includingMU, PCMH, ACO and PCOR

N/A, by 12/2014, 5% completed.

11.2 Develop a staff leadershipdevelopment program


11.3 Inservice/Cross training in priorityareas


11.4 Hire DC Staff Done Nov. 2011, by on-going, 100% completed.11.5 Educate staff and members aboutACA implementation


11.6 Maintain online databases/lists:health data lit, toolkits, gateway

Update CBPR toolkit in collaboration with NACHC by 2014, by 12/2014, 10% completed.

Objective Activity Benchmark/Status12.1 Workforce best practice Identify at least 2 strong workforce development programs per year; promote programs

each year, by 12/2014, 10% completed.

12.2 Peer to peer clinician workgroup 2012 develop a clinicians email network; each year monitor clinicians networkcommunications and identify potential workgroup or webinar topics, by 12/2014, 5%completed.

12.3 Promote consumer leadership Incorporate consumer leadership into 2012 and 2014 conferences; Develop product on theimportance of consumer engagement for TA website in 2013, by 12/2014, 0% completed.

12.4 Promote CHW (community healthworker) models

Identify at least 2 strong workforce development programs per year; promote programseach year, by 12/2014, 0% completed.

11.By 2014, expand thecapacity, knowledge, andleadership skills of AAPCHOstaff in the strategic priorityareas to strengthen therange of support provided tomembers.

By 2014, 20 % (6) AAPCHOMembers will be engaged inthe development andimplementation of anAAPCHO workforcedevelopment program.


Approved(–(March(22,(2011! ! ! ! ! AAPCHO!Strategic!Plan!

!*2!See#Objective#9,#activity1#proposes#an#activity#to#work#with#Board#members#and#member#organizations#to#clarify#definition#of#engagement#for#this#strategic#plan.##No#preAexisting#definition#of#engagement#has#yet#been#submitted#for#consideration,#but#I#believe#there#will#be#a#range#of#activities#options.#

1#

AAPCHO&2011*1014&STRATEGIC&PLAN&&

Vision:!!To!be!the!national!leader!and!critical!voice!for!AA&NHOPI!community!health!centers!and!consumers,!ensuring!that!our!communities!have!better!access!to!affordable,!high!quality,!and!culturally!and!linguistically!proficient!health!care.!!Roles:&

1. Advocate!for!the!Special!Health!Needs!of!AA&NHOPI!Medically!Underserved!Populations!2. GoGTo!Resource!and!Collaborative!Forum!for!Promoting!AA&NHOPI!Health!Strategies!and!Leadership!3. Expand!and!Diversify!Membership!thereby!Extending!AAPCHO!Core!Values!and!Community!Responsive!Care!to!More!AA&NHOPI!

Communities!!Strategic&Priority&Areas:&

1. Health!disparities:!!diseases,!SES!and!SDOH,!Access!and!affordable!C&L!appropriate!care,!health!access!for!immigrants!2. Economic!crisis!&!impact!on!fed/state!funding,!employment,!uninsured!3. HIT,!research!&!evaluation!expertise!and!guidance!4. Strengthening!AAPCHO!and!member!organizations!5. Workforce!recruitment,!development!and!retention!CHC!staff!

!!

PROPOSED&MEASURABLE&OBJECTIVES&STRATEGIC&PRIORITY&AREA&1&:&Health&disparities:&&disease,&SES&and&SDOH,&Access&and&affordable&C&L&appropriate&care,&health&access&for&immigrants&!Objective&1:!!By!2014,!60%!(14)!of!AAPCHO!member!community!health!centers!will!have!received!AAPCHO!TA!support!to!adopt!and!integrate!a!CHC!G!PCMH!model!to!address!the!special!health!needs!(health!disparities,!socio!economic!status,!cultural!and!linguistic!barriers,!immigrants)!of!the!AA&NHOPI!populations!served.!

Activities!related!to!this!objective!may!include:!!1) Develop!complementary!and!coordinated!technical!assistance!with!NACHC!and!PCAs;!2) Leveraging!the!expertise!and!experience!of!member!centers;!3) Identify!and!promote!members’!promising!practices!for!addressing!special!health!needs!and!improving!health!quality!and!population!health.!!!

Interim&Measures:&The!total!number!of!members!receiving!AAPCHO’s!TA!to!strengthen!response!to!special!health!needs!by!year!is:!2012:!3G5;!2013:!4G9;!2014:!8G14.!&!



2#

Objective&2:!!By!2014,!staff!will!have!identified,!developed,!and!promoted!at!least!4G5!innovative!and!sustainable!CHC!strategies!that!contribute!to!high!value!results!related!to!Hepatitis!B,!Diabetes,!CLAS!Standards!and!Immigrant!health!needs!of!medically!underserved!AA&NHOPIs.!!

Activities!related!to!this!objective!may!include:!!1) Development!of!an!effective!model!for!providing!comprehensive!hepatitis!B!services!to!highGrisk!populations;!2) Models!for!improving!diabetes!selfGmanagement!through!partnerships!with!other!CBOs.!

Interim&Measures:&The!number!of!innovative!and!sustainable!CHC!strategy!per!year!are:!2012:1;!2013:2;!2014:2!!

!!!

STRATEGIC&PRIORITY&AREA&2:&Economic&crisis&&&impact&on&fed/state&funding,&employment,&uninsured!!Objective&3:!By!2014,!develop!and!implement!an!advocacy!strategy!to!preserve!funding!and!adequate!reimbursement!for!serving!AA&!NHOPI!population!which!engage*!75%!(10)!of!AAPCHO's!Board!of!Directors!and!increasing!the!engagement!of!AAPCHO's!membership!100%!from!2011!baseline.!!!

Activities!related!to!this!objective!may!include:!!1) Evaluate!and!promote!an!integrated!model!of!care!that!improve!quality!and!lower!health!care!costs!by!2013;!2) Be!proactive!against!financial!threats!such!as!payment!reforms!by!demonstrating!value!through!cost!savings!while!enhancing!access!and!

improving!quality!by!2014;!3) Develop!media!strategy!to!engage!national!and!local!media!by!2013;!!

!!!!2)!Develop!legislative!strategy!to!develop!model!language!for!national/state!legislation!by!2012;!!!!!3)!Develop!administrative!strategy!to!promote!AAPCHO!position!&!recruit!strategic!coGsponsors!by!2012.!

Interim&Measures:&The!number!of!member!centers!engage*!in!advocacy!strategy!by!year!are:!2012:5;!2013:8;!2014:10.!!Objective&4:!By!2014,!develop!and!implement!an!advocacy!strategy!in!partnership!with!other!national!advocacy!organizations/coalitions!to!help!eliminate!5!year!bar!for!immigrants,!as!well!as!promote!inclusion!of!COFA!migrants!for!Medicaid!eligibility!which!will!engage*!at!least!3!of!AAPCHO's!Board!of!Directors!and!increase!the!engagement!of!AAPCHO's!membership!100%!from!2011!baseline.!

Activities!related!to!this!objective!may!include:!!!!!!1)!Develop!media!strategy!to!engage!national!and!local!media!by!2013;!!!!!!2)!Develop!legislative!strategy!to!develop!model!language!for!national/state!legislation!by!2013;!!!!!3)!Develop!administrative!strategy!to!promote!AAPCHO!position!&!recruit!strategic!coGsponsors!by!2012.!

Interim&Measures:&The!number!of!member!centers!engage*!in!advocacy!strategy!by!year!are:!2012:2;!2013:4;!2014:7.!!!!

STRATEGIC&PRIORITY&AREA&3:&HIT,&research&&&evaluation&expertise&and&guidance!



3#

!Objective&5:&&By!2014,!staff!will!develop!and!implement!a!plan!to!engage*!at!least!70%!of!AAPCHO!members!with!EMR!to!build!expertise!in!MU!and!PCMH.!

Activities!&!measures!related!to!this!objective!may!include:!!1) Develop!AAPCHO!Learning!Teams!to!share!and!improve!best!practices!for!integrating!MU!and!PCMH!by!2012.!2) Develop!communications!plan!to!nationally!promote!awareness!and!benefits!of!member!best!MU!&!PCMH!related!practices!by!2013.!3) Develop!&!secure!2!new!MU!&!PCMH!related!grants!and!programs!by!2014.!

!!Objective&6:!By!2014,!expand!AAPCHO!Enabling!Services!Data!Collection!to!at!least!75%!(16)!of!AAPCHO!member!community!health!centers,!and!support!partnerships!with!NACHC,!Homeless!HC,!&!Migrants!HC!to!assist!another!50G100!community!health!centers!collect!enabling!services!data.!

Activities!&!measures!related!to!this!objective!may!include:!!1) Provide!TA!to!increase!the!number!of!AAPCHO!members!submitting!ES!data!to!AAPCHO!to!10!by!2012;!13!by!2013;!16!by!2014.!2) Strengthen!AAPCHO’s!IT!capacity!by!securing!a!full!time!IT!staff!to!optimize!support!and!collaboration!among!members’!staff!by!2013;!3) Develop!MOU!with!NACHC,!Homeless,!and!Migrant!HC!to!clarify!TA!and!support!roles!to!50G100!HC!nationally!by!2012.!

!!Objective&7:!By!2014,!staff!will!develop!and!implement!a!plan!to!engage*!at!least!25%!(5)!of!AAPCHO!member!health!centers!to!build!expertise!in!Patient!Centered!Outcomes!Research!(PCOR)!and!conduct!at!least!one!PCOR!study.!

Activities!&!measures!related!to!this!objective!may!include:!!1) Develop!an!AAPCHO!onGline!PCOR!information!and!resource!center!by!2012;!2) Develop!AAPCHO!PCOR!Learning!Teams!by!2013;!3) Secure!at!least!1!PCOR!grant!with!AAPCHO!members!by!2014.!

!!!!!!!

STRATEGIC&PRIORITY&AREA&4:&Strengthening&AAPCHO&and&member&organizations&!Objective&8:!By!2014,!increase!organizational!funding!by!20%!through!the!development!and!implementation!of!a!3Gyear!business!plan.!

Activities!&!measures!related!to!this!objective!may!include:!!!!!!1)!Identification!of!new!revenue!streams!by!2012;!!!!!!2)!Increase!new!nonGgovernment!revenue!stream!by!20%;!



4#

3)!Increase!total!indirect!revenue!by!at!least!50%!to!help!support!policy,!IT,!and!operations!staff!by!2014.!!!!

!Objective&9:!By!2014,!increase!membership!involvement!by!25%!each!year!through!the!development!and!implementation!of!a!Board!of!Directors!&!membership!engagement!plan.!

Activities!!&!measures!related!to!this!objective!may!include:!1) Development!of!Board!job!descriptions!to!clarify!definition!and!provide!examples!of!Board!and!member!engagement!by!2012;!2) Development!of!communications!plan!(ie.!Newsletters,!facebook,!news!articles)!promoting!impact!of!Board!&!membership!

engagement!by!2013;!3) Development!of!new!member!orientation!process!by!2014.!

!!Objective&10:!By!2014,!expand!membership!by!at!least!3!FQHCs/lookGaGlikes!committed!to!AAPCHO!Guiding!Principles!and!Values!over!the!next!3!years.!

Activities!!&!measures!related!to!this!objective!may!include:!1) Update!MUAC!datasets!to!integrate!2010!Census!data,!to!identify!AA&NHOPI!medically!underserve!priority!areas!by!2013;!2) Conduct!an!comparative!analysis!of!proposed!new!NRM!MUA/HPSA!with!AAPCHO’s!MUAC!criteria!by!2013;!3) Utilize!AAPCHO’s!NAP!Learning!Team!methods!to!enhance!competiveness!of!at!least!6!new!applicants!by!2013.!

!!Objective&11:!By!2014,!expand!the!capacity,!knowledge,!and!leadership!skills!of!AAPCHO!staff!in!the!strategic!priority!areas!to!strengthen!the!range!of!support!provided!to!members.!

Activities!!&!measures!related!to!this!objective!may!include:!1) Secure!a!policy!staff!in!Washington,!DC!before!2012;!2) Secure!IT!staff!to!support!research!and!TA!efforts!by!2013;!3) Increase!number!of!staff!with!knowledge!base!in!relevant!strategic!priority!areas!by!20%!each!year!between!2011G2014.!!4) Develop!an!AAPCHO!Leadership!program!to!increase!50%!of!staff’s!capacity!to!strengthen!the!range!of!support!provided!to!

members!by!2014.!!

!!!!

STRATEGIC&PRIORITY&AREA&5:&&Workforce&recruitment,&leadership&development,&and&retention&of&CHC&staff&!Objective&12:!By!2014,!20!%!(6)!AAPCHO!Members!will!be!engaged*!in!the!development!and!implementation!of!an!AAPCHO!workforce!development!



5#

program.!!!Activities!related!to!this!objective!may!include:!!

1) Promote!at!least!2!existing!workforce!development!programs!targeting!special!populations!by!2012;!!2) Promote!partnerships!to!convene!consumer!leadership!conferences!by!2012;!3) Convene!member!peer!learning!groups!to!promote!member!staff!development!and!retention!by!2013;!4) Developing!workforce!development!partnerships!with!NACHC,!PCAs,!and!other!health!center!related!networks!(ie.!WCN,!Homeless,!

Migrant,!etc.)!by!2013.&&

!

BOD Roles and Responsibilities Draft

Issue: In an effort to promote member engagement and ensure that the roles and duties of AAPCHO’s board of directors are made clear, AAPCHO is creating a Board of Directors Roles and Responsibilities document. AAPCHO and its membership committee, consisting of AAPCHO board members, used four existing models to development its own document. This document was meant to differ from the organizations by-‐laws by giving BOD members a clearer outline of the duties and responsibilities that are expected of this body. Recommendations: In our November conference call, the Membership Committee discussed ways to engage AAPCHO BOD members, clarify expectations of those members, and membership growth. The committee members’ primary recommendation involved the creation of “committees” in which AAPCHO members and its BOD would be expected to participate. These committees would provide a more formal structure that may allow for greater participation from members and BOD on varying levels. These committees would be integrated into the Board Job Description document. Based on the recommendations from our last call, AAPCHO staff believes that ICHS’s (Sample #1) model is most in alignment with the committee’s recommendations. Each of the models reviewed possessed worthy aspects and features, but ICHS’s model was comprehensive, giving balanced attention to both BOD responsibilities and expectations and delineating between the two. Though AAPCHO is national in scope and ICHS more local, ICHS’s document may be tailored and is applicable to AAPCHO and its needs. AAPCHO’s own document may be anchored in two sections: Board Member Position Description and Board Member Expectations and Responsibilities. Alternative third and fourth sections may be: Board Member Attributes and Committee Descriptions (Executive Committee, Policy, Research and Membership). The alternative sections can be considered and further discussed by the Membership committee. Board Member Expectations & Responsibilities Board members have an ethical duty to fulfill the legal responsibilities of a board member with honesty and integrity. Members of the board are expected to exercise the:

1.) Duty of care-‐ the board and its individual members act as any ordinary, prudent person would in the same situation. Board participant should be diligent, attentive and informed.


2.) Duty of obedience – board members act within the requirements of the law and according to the mission, bylaws, rules and regulations of the organization.

3.) Duty of loyalty-‐ board members act always in good faith and in the best interest of the organization. Board members place the interest of the organization before personal or business interests. Specifically, board members must avoid two types of activities

a. Potential conflict of interest – board members will provide full disclosure of any conflict of interest in accordance with the ethics policy

b. Special favors – the terms of any transaction involving a member of the board must be no more favorable to the board member than terms offered to someone with no ties to the organization.

Basic responsibilities of all board members include: 1.) Establish AAPCHO mission and vision 2.) Select Executive Director 3.) Support and evaluate the Executive Director 4.) Establish strategic goals 5.) Assure adequate resource planning 6.) Oversee organizational performance 7.) Establish and comply with all board policies 8.) Enhance the organization’s public image 9.) Represent AAPCHO at community and stakeholder groups 10.) Participate in advocacy and promotion of AAPCHO, AA&NHOPI issues and

positions. 11.) Assess and improve the performance of the board

The following are expectations of members of the Board of Directors for AAPCHO.

1.) Know, believe in and support the mission of AAPCHO 2.) Attend and participate in board meetings as determined by AAPCHO by-‐laws 3.) Participate as a member of at least one board committee 4.) Prepare for all meetings by reading meeting materials provided 5.) Offer strategic guidance and suggestions 6.) Maintain confidentiality 7.) Avoid conflicts of interest 8.) Promote and advocate for AAPCHO 9.) Contribute to AAPCHO’s success through volunteering, in-‐kind services

and/or financial support

Board Member Position Description Duties and Responsibilities of Individual Board Members

1.) To promote the mission and vision of AAPCHO.


2.) To maintain the confidentiality of Board information. 3.) To serve on at least one Board committee (policy, research,

membership/programs, and/or ad hoc committees) 4.) To attend Board and committee meetings regularly. 5.) To review information provided to the Board. 6.) To exercise reasonable business judgment in the conduct of Board business. 7.) To participate actively in Board issues by critiquing reports and providing

innovative resolutions to problems. Preferred Knowledge and Skills of Individual Board Members

1.) Come from a position of leadership within AA&NHOPI communities. 2.) Understand the concept and operation of an AA&NHOPI serving community

health center. 3.) Training and/or experience in one or more of the following areas:

-‐management; law; employee relations; personnel management; social services delivery; health care delivery; marketing/public relations; financial management; community affairs; fundraising.

4.) Ability to read and understand standard financial statements. 5.) Ability to work with others in a Board and committee setting. 6.) Understanding of respective local and national AA&NHOPI populations and

their cultures.

a a p c h oAssociation Of Asian Pacific Community Health Organizations

300 Frank H. Ogawa Plaza, Suite 620 Oakland, CA 94612p 510.272.9536 f 510.272.0817

www.aapcho.org

The Consumer Assessment of Healthcare Providers and Systems Program (CAHPS)Issue Brief

Background: What is CAHPS?The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, developedby the Agency for Health Care Research and Quality, is focused on capturing patients’ andconsumers’ perspectives on their experiences with health care services. CAHPS surveys cover awide range of health care delivery topics including experiences with health plans, primary andspecialty clinicians, and with care delivered in targeted facilities such as hospitals, nursinghomes, and dialysis centers.

The development of the CAHPS program has evolved over three phases: CAHPS I (1996-2001);CAHPS II (2002-2007); and CAHPS III (2007-2012). The first five years of CAHPS focused on thedevelopment of standardized questionnaires for the assessment of consumers’ experience withhealth plans. The second phase of CAHPS involved the development of surveys targeted to carein facilities as well as addressing the usefulness of CAHPS for vulnerable populations. In thethird stage of CAHPS, the program has shifted its focus from development of surveys todevelopment of tools and resources towards refinement of its surveys.

CAHPS is widely used across the U.S. and is significant in that is a standardized tool and hasbeen tested to be valid and reliable. A variety of organizations including health plans,purchasers, state Medicaid programs, and the National Committee on Quality Assurance usedata and analyses from CAHPS surveys for quality improvement purposes including accreditinghealth plans, monitoring performance, accountability, and informing consumers. For example,health care decision makers use CAHPS data to assist and refer unassigned enrollees to specificproviders and facilities.

Implications for Asian American, Native Hawaiian and Other Pacific Islander-Serving ProvidersThere are serious concerns regarding the utility of CAHPS surveys as an instrument to evaluatethe health care experiences of racial/ethnic populations and to accurately assess the quality ofcare provided by community health centers serving culturally and linguistically diversecommunities.

Studies have found racial/ethnic groups respond to patient surveys differently. For example,compared to other populations, Asian patients tend to give negative reports of their health careexperiences. 1 Additionally, there have also been discrepancies on reporting of health careexperiences and overall ratings of care where lower reports do not necessarily correspond with

lower ratings.2 Moreover, CAHPS has been found to be not widely accessible to other limited-English speaking communities other than Spanish-speaking.3

Community health centers have reported lower scores from CAHPS surveys, which haveaffected their overall ranking within health plans. There have been instances in which theinterpretation of scores has resulted in penalties imposed upon health center providers whothen lose referrals of unassigned enrollees.ConclusionGiven the diverse populations served by community health centers and the significance of theCAHPS program in measuring quality of care from the patient’s perspective, concerns regardingthe applicability of CAHPS for racial/ethnic populations should be taken into account by healthcare decision makers and particularly public and private purchasing groups.

Although the timeframe for the development of the CAHPS surveys seems to have evolvedtowards refinement, there may be opportunities to increase awareness of the impact of surveyresults and take into account certain adjustment factors to enable improved decision-making.

Interpretation of survey results and the effects on safety-net providers such as communityhealth centers can have significant impacts on the long-term financial sustainability of theseproviders and facilities, especially as patient ratings and quality improvement measures mayultimately be tied to payment/reimbursement policies.

Additional Information/Resources The Agency for Healthcare Research and Quality’s CAHPS Program Website:

http://www.cahps.ahrq.gov/ CAHPS Program Brief: http://www.cahps.ahrq.gov/~/media/Files/About%20CAHPS/07-

P016.pdf

1 Johnson et al. 2010. “Case-Mix Adjustment and the Comparison of Community Health Center Performanceon Patient Experience Measures.” Health Services Research. 1-21.2 Ibid.3http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/P/PDF%20PatientSurveysCulturalCompetence.pdf

AAPCHO Board of Directors Report

Report Topic: Building Community-Based Research Capacity through Development of an

Institutional Review Board (IRB) in the Community Health Applied Research Network

(CHARN) project.

Submitted by: Rosy Chang Weir

Board of Directors Meeting Date: March 21, 2012

Background and Summary: AAPCHO is continuing to collaborate with member centers on its

CHARN project to develop research infrastructure. Recently, the Patient Centered Outcomes

Research Institute (PCORI), a committee established by Congress through the 2010 Patient

Protection and Affordable Care Act, to define and develop strategies for patient-centered

research, has become very interested in collaborating with CHARN due to its primary focus on

underserved populations.

Through CHARN, AAPCHO is building on the Pacific Innovation Collaborative (PIC) data

registry with data on patients, encounters, selected diagnoses, labs, and medications. AAPCHO’s

data registry will be vital to ensure our communities continue to play a leadership role in

advocating for our population’s needs. As the data registry grows, there will be more

opportunity to conduct research on our populations that health center staff can be involved in

to raise their capacity, and ultimately to reduce health disparities for our communities.

To build capacity in engaging in the research activities, AAPCHO proposes to develop a

Community IRB. We would like to explore the feasibility of hosting our own Community IRB for

our members to use in order to empower our members to conduct research independent of

academic institutions, and to have a larger voice on the conduct and budget of the research

consistent with community mission and values. As our research capacity grows as a result of

CHARN (e.g. data registry), an IRB will be increasingly important to facilitate these efforts.

Please see the attached IRB fact sheet for additional information on the benefits, function, and

maintenance of the IRB.

Additionally, AAPCHO is currently serving as a role model in conducting Community-Based

Participatory Research (CBPR) for the entire CHARN who do not equally value and respect

CBPR principles, and thus do not equally engage their CHCs in the research process. We

continue to uphold our leadership in CBPR, often at a cost of not initially being inclusive of all

member CHCs due to the costs involved in true CBPR. We seek your input and continued

investment in our CBPR principles. With increasing capacity and foundation through CHARN

and the PIC data registry, CBPR can be conducted with more member center involvement.

Overall, our CHARN efforts aim to raise our health centers’ presence in federally-supported

research ventures and other externally funded opportunities and ultimately reduce disparities

for our populations.

Issue(s): Although AAPCHO health centers are interested in doing research, they often need to

do it in partnership with an academic institution which has access to an IRB. Often, the

academic institutions do not engage health centers as an equal partner, leading the research to

be conducted without equal consideration of the mission and value of health centers. In

addition, health centers often surrender control over important research matters such as

budget, data, and publication to the academic institution who often have high indirect rates.

Following the model of other health center networks who have IRBs, AAPCHO can serve to

empower our member health centers to conduct their own research consistent with their

community mission and values. AAPCHO’s IRB will also enable members to conduct projects

sensitive to the cultural, linguistic, and other needs of the population.

Action Requested: Approve development of AAPCHO community IRB and approve your staff

to serve as a volunteer on the IRB (6 hours initial training, and 4-6 hours every 2 months)

Nodal Spotlight 1

Alliance 2

AAPCHO 2

OCHIN 3

Fenway 4

HRSA 5

Methods Madness 6

Clinical Corner 7

Data Management Tips 7Hig

hlig

hts

CommunityHealth AppliedResearch Network

FALL 2011

New CHARN

Conference

call-in information:

Toll Free: 888.858.2133

Toll: 646.746.3001

Pass code: 4057839#

We voted to combine the Research Planning and

Publications subcommittees into a single entity.

We held our 3rd Steering Committee face to face

meeting in Oakland, CA. See below for the

meeting recap!

We have completed the IRB submissions at all

nodes for the Needs Assessment survey, which we

are conducting in coordination with the National

Supported by Grant #UB3HA20236, Health Resources and Services Administration,Department of Health and Human Services

The third steering committee meeting was hosted by

AAPCHO on Aug 24-25, 2011 in Oakland, CA. We

had an amazing turnout with 50 attendees across all

nodes, including HRSA and external advisors. We

also made great progress on key issues. Here is a

recap of the key discussions, decisions and next

steps that came from this meeting:

� We have a logo! A slate of options developed by

the CDMCC in conjunction with the Communica-

tions and Community Relations subcommittee

was shown to the Steering committee for a

formal vote. You’ll see the winner on the front

page of this newsletter.

Association of Community Health Centers, Inc.

(NACHC).

We have begun the nomination process for the

second (and final) seating of project officers.

The data registry has made considerable strides

and finalized documents (data dictionary,

submissions document, protocol) were completed

in October 2011.

� The process for nominating and voting for the

next seating of officers was formalized.

� The work plan was reviewed and agreed upon

(with some items still to be added, including

performance measures and nodal deliverables).

� The Research Planning subcommittee presented

14 concept proposals, collected from all nodes

and external advisors with the goal of selecting

those we will a) emphasize for development for

additional funding and b) pursue with current

funds and complete within the funding period.

The projects receiving the highest votes were:

CHARN Project Updates

51132 10/11 CHR

CHARN Steering Committee Recap

Quarterly Newsletter

(Continued on Page 3)

CHARNC

2

Alliance Nodal News

In June 2011, the Alliance Node held a

Research Infrastructure Meeting in

Chicago. Attendees were academic

partners, PIs from the 7 affiliate sites,

and experts in comparative effectiveness

research, research in safety net settings,

and data warehousing. One of the key

outcomes was a set of “Priorities and

Principles” to guide the Alliance’s approach

to patient-centered outcomes research and

specifically to guide decisions about which

opportunities are of highest importance to

our network’s mission. The node has three

aims: (1) Inform the larger health care

community of our priorities; (2) Serve as a

benchmark against which to measure our

internal research ideas, and; (3): Evaluate

research ideas coming from outside

the network.

The Alliance node has been busy working

on administrative components of its

infrastructure. Data Use Agreements

between CHARN CHCs and Alliance have

been drafted and are currently under legal

review. The indirect rate issue is being

explored with local and federal resources.

The Alliance Node has conducted the first

of seven in-person site visits to our CHC

affiliates to systematically assess capacity

to generate and carry out patient-centered

research studies, and has begun develop-

ing a 2-year fellowship program.

This fall, the Alliance Node is finalizing

technical requirements for its data

warehouse, and selecting a vendor.

Several “data marts” have been

constructed to establish patient cohorts

of interest, and the node has purchased

and is implementing video

conferencing hardware.

The Alliance node is involved with several

research projects: the Framingham Project,

in which all seven CHARN affiliate sites are

studying the impact of clinical decision

support on statin prescriptions; the

Undiagnosed HTN project which tests an

algorithm to identify likely hypertensive

patients; smoking cessation, in which

several affiliate sites are identifying

patients for a large clinical trial at our

academic affiliate that combines the

nicotine patch with intensive cognitive

behavioral therapy; and a study of asthma

triggers, in which most affiliate sites are

participating in a study to assess the

impact of decision support on the

documentation and management of

environmental triggers in children

with asthma.

In May 2011, the Alliance Node partnered

with Northwestern University to submit an

AHRQ grant. The grant proposed four

research ideas, most of which were

informed by direct input from CHARN

affiliate clinicians. Two of the proposed

projects are to occur in CHARN Affiliate

sites. These are: (1) an intervention to

increase colorectal cancer screening using

repeat screening, automated phone calls,

and a care coordinator/patient navigator

(this project will be implemented at our

Erie CHC), and; (2) using the EHR to

identify patients who at risk for

cardiovascular screening using lipid

screening and consideration of statins.

AAPCHO Nodal News

In August 2011, the AAPCHO node

convened its first face-to-face meeting with

its National Research Advisory Committee

to discuss future research activities and

strategic planning. Afterward, AAPCHO

hosted the CHARN Steering Committee

meeting in downtown Oakland, CA, which

included a walking tour of Asian Health

Services and its surrounding community.

AAPCHO is currently developing data use

agreements with its affiliate CHCs and has

newly hired a database programmer to

assist with building its data infrastructure

for the CHARN registry implementation. In

addition, AAPCHO submitted comments to

PCORI on the current working definition of

patient centered outcomes research.

AAPCHO continues to lead the CHARN

needs assessment/training workgroup, as

well as the enabling services research

workgroup. The CHARN Research

Capacity Needs Assessment was approved

by the Waianae Coast Comprehensive

Health Center IRB, which will allow the

survey to be implemented at AAPCHO

project sites beginning in November 2011.

Furthermore, abstracts for the CHARN

needs assessment project will be

presented at the Community-Campus

Partnerships for Health (CCPH) 2012

annual conference in collaboration with

National Association of Community Health

Centers. All nodes have expressed interest

in collecting data on enabling services

uniformly and conducting studies to

evaluate how enabling services impact

health outcomes. The CHARN nodes have

completed the enabling services

needsassessment to better understand

their capacity and needs in collecting and

reporting enabling services data.

Important upcoming nodal

events include:

AAPCHO’s second nodal face-to- face

meeting/research training with NYU at

Charles B. Wang Community Health

Center in New York City

AAPCHO’s 25th Anniversary “Cultivating

Traditions of Wellness 2012: Advancing

Community Leadership” Conference and

Gala, March 19-20, 2012 in Washington,

D.C. For more information on the

conference, please visit the official event

website at: http://ctow.aapcho.org/

Contact: CHARN Newsletter

Stefan Massimino, 503.528.3995

[email protected]

3

Congratulations! Jen DeVoe, our node

PI, gave birth to a baby boy on July 9,

2011: Bennett DeVoe Straub. Christine

Nelson filled in as interim PI during Jen’s

maternity leave.

The OCHIN node, together with our

academic affiliate and two of our CHC

affiliates, published an article in the

September/October 2011 Journal of the

American Board of Family Medicine, a

special issue on PBRNs: “Developing a

Network of Community Health Centers

With a Common Electronic Health Record:

Description of the Safety Net West

Practice-based Research Network.”

(Full citation below.)

The OCHIN node welcomed a visit in July

from Dr. Kurt Stange, an internationally

recognized expert in primary care research

in Practice-based Research Networks.

Dr. Stange consulted with our team and

attended the OCHIN Board of Directors

meeting, where he spoke eloquently about

the value and importance of research.

OCHIN Nodal News

In August 2011, the OCHIN node was

awarded an R01 from NHLBI entitled

“CARDIAC: Assessing a Medicaid

Randomized Insurance Experiment within

Community Clinics.” Jen DeVoe is the PI

on this four-year grant to assess how

public insurance policy changes have

impacted receipt of CVD preventive care

for the OCHIN clinic population. The study

aims to provide a national model for linking

EHR and Medicaid data for preventive care

surveillance in insured and uninsured

safety net populations.

Also in August, OCHIN hit a landmark with

over 1 million distinct patients in our EPIC

database. Our research analyst, Patti

McIntire, presented to peers in the national

PBRN CER Learning Group about OCHIN,

our research department, and several

innovative CER projects.

OCHIN recently completed interviews for a

PBRN key informant project. We

interviewed 18 founding and current

members of the Safety Net West PBRN,

assessing what hindered or facilitated

the group’s start in 2004/ 2005 and

exploring strategic visions for the next

five years.

Our node steering committee met

monthly during this quarter, and seven

OCHIN node representatives attended

the CHARN Steering Committee

meeting in Oakland. At the Oakland

meeting, the OCHIN node presented

three research concept proposals

developed through a series of stake-

holder meetings including critical input

from community clinicians, OCHIN

executives, and affiliated researchers.

Since then, the OCHIN node team has

met with community stakeholders to

discuss and prioritize the eight CHARN

research concepts identified for further

cross-nodal development. We received

general support for the topics selected

and will staff all working groups.

Recap from the August Steering Committee Meeting

� Identifying high risk CVD patients

and patients with undiagnosed

hypertension using EHR data*

� Enabling services

� Document the prevalence of

smoking and the frequency of

advice and counseling for

smoking cessation across several

Community Health Centers

� Physician/Provider Survey:

Factors unique to safety net

settings which impact adherence

to evidence-based guidelines

(Moments of Compromise)

� Barriers and Facilitators to

Routine HIV Testing in

Community Health Centers

� Improving colorectal cancer

screening

� Use of electronic patient reported

outcomes (ePRO) in the clinic

� Next steps included further

examination of the PCORI RFA,

continued emphasis on data

warehouse development and IRB

approvals/DUA executions to

facilitate registry development.

Our Next Steering Committee

Meeting

Please join us for our next Steering

Committee meeting in Washington,

DC on February 1-2, 2012. As we are

in close proximity to various funding

agencies, we hope to make this an

emphasis of the meeting, including

hosting a panel staffed by represent-

atives from various federal agencies

Details will be communicated as

they’re finalized. We hope to see

you in DC!

*Registry project to be completed in currentfunding timeframe

(Continued from Page 1)

DeVoe J, Gold R, Spofford M, Chauvie S, Muench J, Turner A, Likumahuwa S, Nelson C. Developing a Network of Community

Health Centers With a Common Electronic Health Record: Description of the Safety Net West Practice-based Research Network

(SNW-PBRN). Journal of the American Board of Family Medicine 24 (5): 597-604 (2011).www.jabfm.org/cgi/content/short/24/5/597

Fenway Nodal News

The TFI node has two new hires:

Brad Zimmerman, a Junior Programmer/

Analyst, will provide programming and

data support to the CHARN project. Brad

recently graduated from Purdue University

with a major in Computer Science and

minor in Psychology. Brad is versed in a

number of computer languages and is a

co-author of a book about programming

with PHP. Brad is also a member of Reach

Out for Computer Science, a volunteer

group that introduces computer science to

elementary school children. Robert DeLeon

has worked at Chase-Brexton for nine

years and recently joined the CHARN

team as a Decision Support Junior

Analyst. He was born and raised in

Manila, The Philippines, started out as

an administrative assistant to the Chief

Medical Officer and then transitioned to the

IT Department. Robert’s computer training

has been mostly “on the job”; he is also a

part-time student at Towson University

majoring in Computer Information Systems.

The Fenway Institute is involved with

national studies of HIV using EMRs

and is planning to import the studies to

participating CHARN CHCs. These

studies include:

The Center for AIDS Research (CFAR)

Network of Integrated Clinical Systems

(CNICS) study: This the first electronic

medical records-based resource network

designed to integrate clinical data from

the large and diverse population of HIV-

infected persons receiving care at CFAR

sites. To date, more than 20,000

participants have been enrolled, including

more than 2,650 Fenway patients. Fenway

has collected behavioral data on more

than 1000 participants and more than 600

patients have provided blood specimens.

Efforts are underway to analyze patterns

and prevalence of substance use and

sexual risk-taking as well as to understand

regional and other demographic variation

in this cohort. In the CNICS Co-Morbidities

Study, additional information is being

collected to include any inhaled steroid

medications, to determine if concurrently

taking these with anti-retroviral (ART)

medications makes it more likely that

patients will have a detectable viral load.

PROMIS: PROMIS is a National Institute

of Drug Abuse sub-study in which Fenway

is one of four participating CNICS sites.

PROMIS seeks to (1) extend Patient

Reported Outcome Measurement Informa-

tion System domains to HIV-infected

individuals, (2) advance psychometric

techniques for identifying and accounting

for biased test items including differential

item functioning (DIF) from data

administered with computer adaptive tests

and (3) broaden patient reported measures

and outcomes research envisioned by

PROMIS to routine clinical care. PROMIS

will administer questionnaires to look at

depression and anxiety with the goal of

helping medical providers address these

concerns with patients.

NA-ACCORD: Fenway was accepted

into the North American AIDS Cohort

Collaboration on Research and Design

(NA-ACCORD) database research project.

NA-ACCORD is part of the International

epidemiologic Databases to Evaluate

AIDS (IeDEA), and is designed to be

widely representative of HIV care in the

U.S. and Canada. The project includes

investigators who have a high level of

scientific and clinical experience, and has

an efficient structure for harmonizing data

and conducting analyses. NA-ACCORD is

one of seven regional HIV collaborations

supported by the NIH as part of IeDEA.

Fenway will be the 23rd HIV cohort from

North America. We anticipate that our first

data upload will occur in November 2011.

HIV Research Network (HIVRN): Fenway

recently joined HIVRN, a project dedicated

to gathering and analyzing timely and

relevant data on the accessibility, quality,

utilization, safety, and costs of health care

services provided to persons with HIV

disease. HIVRN is a network of HIV care

providers from various health care settings

including hospitals with and without a

university affiliation, as well as community-

based settings. The project supports an

ongoing process of comprehensive data

collection going back to 2000 from a

diverse array of providers and patients.

The data is assembled and analyzed

rapidly; this flexible process enables

data collection to be modified to focus

on emerging issues.

4

Subcommittee Schedule Time

Executive Committee 1st & 3rd Friday each month 8:30am Pacific, 10:30am Central, 11:30am Eastern

Steering Committee (in lieu 1st Friday, every other month 11am Pacific, 1pm Central, 2pm Easternof Executive Committee call)

Research Planning & Publications 1st Wednesday each month 10am Pacific, 12pm Central, 1pm Eastern3rd Tuesday each month 12pm Pacific, 2pm Central, 3pm Eastern

Communications & Community Relations 2nd & 4th Wednesday each month 9:30am Pacific, 11:30am Central, 12:30pm Eastern

IRB/Regulatory 2nd & 4th Tuesday each month 1pm Pacific, 3pm Central, 4pm Eastern

Data Sharing & Registry Design 1st & 3rd Friday each month 1pm Pacific, 3pm Central, 4pm Eastern

*All CHARN call-in information is constant across meetings (Toll Free: 888-858-2133, Toll: 646-746-3001; Pass code = 4057839#)

CHARN Subcommittee recurring call schedules

5

The Health Resources and Services Administration (HRSA)

The Health Resources and Services

Administration (HRSA), an agency of the

U.S. Department of Health and Human

Services, is the primary federal agency for

improving access to health care services

for people who are uninsured, isolated, or

medically vulnerable.

HRSA’s mission is to improve health and

achieve health equity through access to

quality services, a skilled health workforce

and innovative programs. HRSA has four

key goals: Improve Access to Quality Care

and Services, Strengthen the Health

Workforce, Build Healthy Communities;

and Improve Health Equity.

Made up of six bureaus and nine offices,

HRSA provides leadership and financial

support to health care providers in every

state and U.S. territory. HRSA grantees

provide health care to uninsured people,

people living with HIV/AIDS, and pregnant

women, mothers and children. HRSA

grantees also train health professionals

and improve systems of care in rural

communities.

Since 1943, the agencies that were HRSA

precursors have worked to improve the

health of needy people. HRSA was created

in 1982, when the Health Resources

Administration and the Health Services

Administration were merged.

For more information, please visit

http://www.hrsa.gov/index.html

HRSA Spotlight

Kaytura L. Felix, MD, works in the

Health Resources and Services

Administration’s (HRSA’s) Office of

Planning, Analysis and Evaluation,

where she leads efforts to expand,

build, and strengthen community-

based program evaluation and

research. Prior to that, she was the

chief medical officer and director of the

Office of Quality and Data in HRSA’s

Bureau of Primary Health Care and

senior advisor on Minority Health at the

Agency for Healthcare Research and

Quality (AHRQ). She was a leader in

the first department-wide collaboration

to recognize and fund Community-

Based Participatory Research (CBPR),

an editor of the Journal of General

Internal Medicine’s first special issue

on CBPR, and a founding editorial

board member of Progress in

Community Health Partnerships, a

national peer- reviewed journal.

Kaytura L. Felix, MD

Project Officer Spotlight

Robert Mills is a Health Statistician at

the HIV/AIDS Bureau of the Health

Resources and Services Administration

(HRSA/HAB). He is a project officer for

four community center based research

sites that are part of the Community

Health Applied Research Network

(CHARN). He is a project officer for the

Regional Health Information Integration

Project, a HAB Special Project of

National Significance (SPNS) initiated

by the Center for Health Policy at Duke

University. Robert is also a member of

the Technical Advisory Group and the

Data Subcommittee of the HIV

Research Network (HIVRN),

Previously, Robert was a Statistician

in the Poverty and Health Statistics

Branch of the U.S. Census Bureau.

From 2000 to 2004, he produced

the annual report ‘Health Insurance

Coverage in the United States,’ the

official source of national and state

estimates of the number of people of

who do not have health insurance.

Robert received his PhD in Social

Science and Health Care from the

University of Connecticut and his

Masters in Sociology of Marriage

and the Family from the University

of Oklahoma.

Robert Mills, PhD

Project Officer Spotlight

6

Methods Madness

Regression Discontinuity Design (RDD)—Mary Ann McBurnie

The Regression Discontinuity Design

(RDD) is a useful method for determining

whether a treatment is effective. In studies

that use RDDs, participants are assigned

to comparison groups based on a cutoff

score for a continuous measure, such

as blood pressure, taken before the

intervention begins. This design is very

common as it often mimics what happens

in clinical settings, where, for example,

patients would be prescribed blood

pressure medicine only if their blood

pressure exceeded safe limits. In its

simplest form, the RDD is a pre-test-post-

test comparison. This unique way of

assigning people to groups is a major

advantage of RDDs. This approach is

desirable when targeting an intervention

to people who most need it, rather

than randomly people to control and

treatment groups.

Consider a hypothetical RDD study in

which we are interested in assessing the

effect of a new treatment for patients with

high blood pressure. We would like to

evaluate the new treatment among patients

with systolic blood pressures of 150 mmHg

or higher: Patients with systolic bp over

150 will get the new treatment (treatment

group) and patients with systolic bp

under 150 will get standard treatment

(control group).

The figure below illustrates what the

outcome might look like if our new

treatment lowers systolic blood pressure in

those whose pre-treatment measure was

more than 150. The vertical line represents

the cut-off point of 150, the solid lines

represent the association between pre- and

post-blood pressure measures in both the

treatment and control groups and the

dashed line indicates the association we

would expect to find in the treatment group

if the treatment had no effect.

Well designed RDDs provide unbiased

estimates of intervention effects near the

cut-off threshold as long as the relationship

between the treatment and outcome is

correctly modeled. Care must be taken to

assure that a non-linear relationship is not

mistakenly interpreted as a discontinuity

associated with a treatment effect.

However, RDDs have substantially lower

power than randomized experiments, and

hence either require a larger sample size

or the tolerance of a higher risk of failing to

detect a significant intervention effect (type

II error). The strength of the RDD depends

on 1) the assumption that there is no

spurious discontinuity in the pre-post

relationship which happens to coincide

with the cutoff point and 2) that we know

enough about the science that we can

correctly model the pre-post relationship.

When What Where Submission Deadline

November 12-16, 2011 North American Primary Care ) Banff, Alta, Canada Closed Research Group (NAPCRG (April 15, 2011)

February 1-2, 2012 CHARN Steering Committee Washington, DC N/A

April 18-21, 2012 Community-Campus Partnerships Houston, TX Closed for Health (CCPH) 15th (September 26, 2011)AnniversaryConference

March 19-20, 2012 AAPCHO’s 25th Anniversary Washington, DC N/AConference and Gala

June 20-21, 2012 CHARN Steering Committee Boston, MA N/A

September 7-11, 2012 Community Health Institute Orlando, FL May 3, 2012(CHI) & EXPO

September 2012 CHARN Steering Committee Chicago, IL N/A

2011-2012 Conferences and Trainings

100

120

140

160

180

200

postbp

100 120 140 160 180 200sysbp

CRF Number

CRF Acronym CRF Name Baseline

B1 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12

1001 CAF Conventional Activities of Friends (Adolescent Only) X* X X X1003 IEC Inclusion-Exclusion Criteria (Adolescent Only) X*1004 PPA Parenting Practices (Adolescent Version) X* X X X1005 PDA Peer Delinquency Scale (Adolescent Only) X* X X X1006 RBS Risk Behavior Survey (Adolescent Only) (CAB) X* X X X1009 CSB*** Confidentiality Self-Report - Blind (Adolescent Only) X* X X X X X X X X X X X X1013 DPA DISC - Predictive Scale (Adolescent Version) X* X1015 SUB DISC - Generic Youth (Adolescent Only) X* X1016 TLF*** Timeline Follow-Back (Adolescent Only) X* X X X X X X X X X X X X1017 UDS*** Urine Drug Screen (Adolescent Only)(CAB) X* X X X X X X X X X X X X1018 YSR Youth Self-Report for Ages 11-18 (Adolescent Only) X* X X X1021 DEM Demographic (Adolescent Only) (CAB) X*1022 DAA Demographic Addendum for Adolescents (Adolescent Only) X*1024 NYS National Youth Survey - Delinquency Scale (Adolescent Only) X* X X X1030 ENR Study Enrollment Form (Adolescent Only) X*1031 RAN Study Randomization (Adolescent Only) X1032 TER**** Study Termination (Adolescent Only) X

4009 CSR Confidentiality Self-Report - Non-Blind (Adolescent and Parent) X* X X X4010 FES Family Environment Scale (Adolescent and Parent) X* X X X4011 AEC** Adverse Event CRF - For Family Members X* X X X X X X X X X X X X4012 CSP** Consent Summary Form - For Family Members X* X X X X X X X X X X X X

* To be performed before randomization** To be used for all family members. ** AEC Form will be issued and utilized only when an AE is reported on as needed basis*** Administered by Blind Research Assistant Only****Scheduled to be collected at T12, but may be collected earlier if participant is terminated prior to completion of study

Post Randomization

Adolescent Only

Adolescent & Parent

Identification of Undiagnosed Hypertension

The “Undiagnosed Hypertension Project” is based on initial work

done by Dr. Michael Rakotz, a Family Practitioner at Northshore

University HealthSystem in Evanston, IL. Dr. Rakotz worked with

clinical informatics teams to run queries looking for patients with

unrecognized hypertension. The team developed an algorithm

run on Northshore’s EHR (Epic) database to look for current

patients whose historic blood pressure measurements indicated

that they might have hypertension, but who had not been

diagnosed or treated. Dr. Rakotz found that there are significant

numbers of patients—as many as 15-25% with elevated blood

pressures—who were not being recognized or managed. The

primary aim of the CHARN project is to attempt to replicate Dr.

Rakotz’s findings, which represent a largely Caucasian,

English-speaking, insured population. The Alliance Node has

already tested these algorithms and shown consistent results

with an indigent, largely uninsured Latino population, using the

GE Centricity EHR. Demonstrating the extent of unrecognized

and untreated hypertension among the CHARN population and

subpopulations will provide background for development of

research projects designed to address this significant issue. In

Phase 1, we will run a standardized, EHR-based algorithm on

databases of Nodal health centers with a fully live EHR to

identify a list of patients with undiagnosed Hypertension. In

Phase 2, we will run the same algorithm on data in the national

CHARN registry (once populated with data from all four

Research Nodes), and compare results from local Node queries

with the query of the national registry.

Framingham Risk Score: Specify and Test an EHR-based

Algorithm for Identifying Population for Primary Prevention

of Cardiovascular Disease

This study will build on work underway through Northwestern

University’s recently funded Center of Excellence grant. One of

the prevention projects under this grant is to identify patients at

moderate to high risk of cardiovascular events using the

Framingham Risk score run against clinical data in the EHR.

The primary aim is to systematically and reliably identify patients

at moderate or high risk for cardiovascular events in the next 10

years, and assess whether or not they are currently taking a

statin. The Alliance Node is currently testing the use of clinical

decision support in its EHR, which alerts a provider to prescribe

a statin for patients at moderate or high risk, or prompts the

provider to record missing data so that the Framingham score

may be calculated. Demonstrating the extent of primary

prevention of cardiovascular conditions among the CHARN

population and subpopulations will provide background for

development of research projects designed to address this

significant issue. In Phase 1, we will develop specifications for

an algorithm to run the Framingham Risk Calculator against data

in the national CHARN registry. After a validation process, the

research team will outline an intervention for populations at

highest risk for not receiving appropriate preventive

cardiovascular therapies, and prepare a proposal for funding as

Phase 2.

Two Initial CHARN registry projects

A schedule of assessments (SoA) is developed

to identify the activities that are to be performed

at each time period of the study in accordance

with the protocol; and defines the acceptable

window of time in which the activity can or must

be performed. Time periods may be defined by

such things as study visit number, participant

contact number, or phase of the study. Activities

might include such things as assessment of

specific data collection forms, timing of a partici-

pant reminder call, and collection of specimens.

An SoA is used as an easy reference during

quality assurance of participant materials to

ensure that there are no protocol violations due

to inaccurate timing of a study activity. The

SoA can also be used to create a study visit

checklist, so that the data collection sites

can be certain of which activities need to be

performed during each time period.

A sample SoA is shown below.

Clinical Corner

Data Management Tips

Study Schedule of Assessments—Reesa Laws

7

NORC | Understanding the Impact of Health IT in Underserved Communities and those with Health Disparities

Case Study Report: Association of Asian Pacific Community Health Organizations (AAPCHO)’s Enabling Services Accountability Project and Pacific Innovation Collaborative – using health IT to ensure patients receive more than just health care

“AAPCHO’s Enabling Services Accountability Project increases Electronic Health Record (EHR) data collection on enabling services and studies the impact of these services on health care access and outcomes. Overall, the project… illustrate[s] the role enabling services play in increasing access and quality of health care for medically underserved communities of color, providing compelling data to adequately compensate health centers for delivering these services.” –Description of ESAP mission and goalsi

Report Summary

Intervention and Setting

The Enabling Services Accountability Project (ESAP) is a collaborative effort between AAPCHO and four project sites included in this case study:

International Community Health Services (ICHS) – Seattle, WA

Charles B. Wang Community Health Center (CBWCHC) – New York, NY

Waianae Coast Comprehensive Health Center (WCCHC) – Waianae, HI

Kalihi-Palama Health Center (KPHC) – Honolulu, HI

ESAP’s work standardizes definitions of enabling services and develops a systematic method for collecting data on usage of these services in a consistent manner. For this case study, NORC explored 1) the specific role electronic health records (EHRs) play in documenting and tracking these enabling services at each of these sites; 2) how broader efforts, such as the Pacific Innovation Collaborative (PIC) can allow for cross-health center comparisons of the needs and provision of enabling services; and 3) the relationship between enabling services and improved outcomes.

Target Population

Demographics vary by project site, but generally include low-income, uninsured and/or underinsured Asian Americans, Native Hawaiians, and other Pacific Islanders (AA & NHOPIs).

Technology Description

Use of templates to capture enabling services using Electronic Health Records (EHRs):

NextGen (ICHS, WCCHC)

GE Centricity (CBWCHC, KPHC)

Use of templates to manage detection and treatment of Hepatitis B using an EHR (CBWCHC)

Funding and Start-up

PIC funding: U.S. Department of Health and Human Services (HHS).

ESAP funding: Initially funded by the Agency for Health Research and Quality (AHRQ), HHS Office of Minority Health, and the California Wellness Foundation.

Data and Analysis

Content analysis using NVivo for a series of in-person and telephone discussions with program administrators, staff, providers, and patients including:

Administrators and Staff from ICHS

• Chief Medical Officer, Chief Financial Officer, Clinical Operations and Health Services Director, IT Manager, Data Supervisor, Patient Access Manager, Community Advocate,


CASE STUDY: AAPCHO – ENABLING SERVICES ACCOUNTABILITY PROJECT | 2

Health Educator Lead, Mid-Level Provider

Administrators, Staff, and Patients from CBWCHC

• Chief Medical Officer, Chief Financial Officer, Chief Operating Officer, Chief Executive Officer, Head of the Hepatitis B Screening and Treatment Program, Director of Research and Evaluation, Clinical Informatics and IT Staff, Social Work Manager, Hepatitis B and Social Work Patients

Administrators and Staff from WCCHC and KPHC

• Chief Information Officer, EHR Department Manager, three Program Managers and Staff Members

Key Take-Aways

• Enabling services play a substantial role in patient care and positive patient outcomes at these health centers.

• Tracking enabling services in a standardized and consistent way through the use of health IT can improve patient care and outcomes.

• Creating EHR templates and flow sheets plays a critical role in meeting specific patient needs.

Introduction

The four project sites included as part of this case study belong to the Association of Asian Pacific

Community Health Organizations (AAPCHO). AAPCHO works with a variety of organizations and

health centers throughout the United States “to create a national voice for the unique and diverse health

needs of Asian Americans, Native Hawaiians, and other Pacific Islanders (AA & NHOPI) communities

and advocate for the empowerment of community health providers that serve those needs.”ii Established

in 1987, AAPCHO is a national not-for-profit association of 29 community-based health care

organizations, mostly federally qualified health centers, dedicated to promoting advocacy, collaboration,

and leadership that improves the health status of AA & NHOPIs. AAPCHO advocated for policies and

programs that improve the provision of health care services that are community-driven, financially

affordable, linguistically accessible, and culturally appropriate.iii

The Asian American, Native Hawaiian, and other Pacific Islander populations include many different

cultures, languages, and health needs. In fact, according to AAPCHO, AA & NHOPIs in the U.S.

represent over 49 ethnic groups and more than 100 different languages.iv These groups often experience

disparities in access to care and health status when compared to non-Hispanic Whites. For instance,

according to the U.S. Census, over 17% of single-race Asians in the U.S. did not have health insurance

coverage in 2009.v Additionally, AA & NHOPIs suffer disproportionately from diseases such as

tuberculosis, diabetes, hepatitis B, and cancer.vi AA & NHOPIs aged 35-54, in general, have a 1.3 times

higher relative risk of death from stroke than Whites; 73% of Japanese American men have high blood

pressure. Furthermore, Asian American women have the lowest rate of cervical cancer screening (45%),

while the rate for White Americans is 63%.vii

Because of their unique language and health needs, and limited access to health insurance, many AA &

NHOPI communities rely heavily on community health centers such as those included in this case study.

These health centers often provide a range of non-clinical services, such as financial counseling, housing

and food assistance programs, language services, immigration support and health education. The

participating health centers refer to these services as “enabling services” and emphasize their critical



Sources of Funding

• PIC funding came through the U.S. Department of Health and Human Services (HHS)

• ESAP was initially funded by the HHS Office of Minority Health and the California Wellness Foundation

“The enabling services (tracking) started in 2004 and it started out on

paper but what we did …was

develop...what we mean when we say health education. So the definitions

are the same among the members so we can get comparable data

points...we standardized the

nomenclature so we can collect data and say there is some level of

consistency.” ICHS Staff Member

importance to support the care received by many low-income and minority patients.viii In many cases,

health centers must address the financial, educational, housing and nutritional needs of these populations

to achieve improvements in health. In addition, effective health care delivery for these populations often

requires health care and counseling services to be delivered in a language other than English to better

ensure complete understanding.ix Enabling services seek to increase access to care and the effectiveness

of care that’s delivered. They play an important role in reducing disparities experienced by many

underserved groups.

Potential benefits of using an EHR to track enabling services. In general, using an EHR

effectively can result in benefits such as improved productivity (e.g., more efficient handling of specific

patient needs), financial improvements (e.g., more efficient billing or more complete documentation for

reimbursements), and improvements in quality of care (e.g., better chronic disease management or more

rapid access to patient information).x The health centers participating in the Enabling Services

Accountability Project (ESAP) track enabling services using their EHRs in order to illustrate the positive

impact that enabling services have on health outcomes, and to better measure the use of these services in

each clinic. By using an EHR to capture this information, these health centers increase their ability to

track and document the services they provide, and through efficient access to their records, they can

effectively communicate with policymakers and funders who can support reimbursement of enabling

services. Additionally, once these health centers use their EHRs to consistently capture and report on

enabling services, a broader initiative such as the Pacific Innovation Collaborative (PIC) can assist with

cross-health center comparisons of the needs and provision of enabling services as well as the relationship

between these services and improved outcomes for health centers serving AA & NHOPI groups across

the nation.

Key functionality and uses. The four AAPCHO

sites included in this report utilize two different EHR

systems to document and track enabling services: ICHS

and WCCHC use NextGen while CBWCHC and KPHC

use GE Centricity. Each clinic uses the standardized data

elements developed by the ESAP and incorporated them

into templates that allow case workers and other staff to

document the specific type of enabling service provided

and amount of time spent in each encounter. The clinics use the enabling services data captured in the

EHR to run reports on the use of these services and to track the impact of these services on patient care,

access and health outcomes both within a given health center and across several health centers through the

PIC initiative.

Encouraging Adoption & Implementation

In this section, we discuss various strategies employed by

these four community health centers for encouraging adoption,

implementation and use of EHR systems.

AAPCHO oversight of the ESAP encouraged clinics’ use

of health IT to track non-clinical services. The four project

sites varied in their stage of adoption, implementation, and use

of EHRs to track non-clinical enabling services. For instance,



“…about 45 percent of patient[s] are below 100 percent

FPL [Federal Poverty Level], 80

percent are API [Asian & Pacific Islander], 64 percent of patients

are language barrier. [At least] 70 percent need some type of

enabling services.”

ICHS Staff Member

“We actually design the form, put

that form in the training EHR and (then) ask the users to test it to see

how easy it is…If they don’t like it then we can modify it. Mostly we

want to keep the workflow so that it

is not affected by this data capturing. We keep the workflow the same.”

CBWCHC Staff Member

WCCHC implemented their EHR in the early 2000s and currently uses it to actively track enabling

services. In contrast, only the main downtown location of KHPC currently uses an EHR. While KPHC

plans to implement an EHR in the near future in another location, these other locations still uses paper

records to track enabling services.

While the ESAP did not necessarily play a role in the decision to implement EHR systems at these

community health centers, it helped encourage the use of these systems to track enabling services.

Through the ESAP, AAPCHO worked closely with the health centers included in this case study to

develop standardized definitions and data collection methods for enabling services. By relying on input

from individual clinics, AAPCHO ensured the appropriateness of categories identified for data collection

for the populations their member health centers serve. Once stakeholders from across the ESAP centers

defined these categories, the centers began work towards establishing templates to collect enabling

services information in a structured way, either via paper or by building interfaces into their existing

EHRs. In many cases, the centers, using standardized data elements and categories, leveraged their EHRs

to report on enabling services and the relationship between these services and clinical quality

improvement measures. As one staff member from WCCHC noted, “As far as enabling services, prior to

a couple years ago, we were collecting that information on paper. We didn’t have anything in our EHR to

collect for what services were being provided…We created an electronic form to capture the services

provided. We listed all the things we provide like transportation, interpretation, financial services – all

those things are now documented and captured in units of time….”

Considering existing workflow while designing and incorporating new templates can increase

provider buy-in. Each clinic customized its EHR in-house to create templates necessary for tracking

enabling services. Stakeholders considered the user’s (usually the case workers’) needs in creating these

customized systems. At CBWCHC, for example, the IT team worked to mitigate the impact of changes to

the EHR on clinician workflow by asking users to test it after it has been designed.

Similarly, staff at WCCHC discussed how provider input helped ease the transition of tracking enabling

services via the EHR. One clinic stakeholder explained the process to develop templates, noting they

included users in the design phase, which allowed individual

users to “make it their own”. This stakeholder described the

process, noting “Not only did we create an electronic form to

capture the services provided, but we made sure it integrated

it into that user’s workflow…for example, for the case

manager, we wanted to make sure that not only are we

creating a template to capture the service, but also how does it

works in terms of [how] they are interviewing a patient, are

they capturing the notes they need to document?...[We try to]

make it so that is it easy enough that with one click these things are getting filled out.”

Impact and Consequences

In this section we review some of the impacts of EHR adoption and

implementation as noted by the individuals we spoke with across all

four ESAP project sites.



“I think with the EHR it is much better because we can track

[enabling services] better and we don’t miss anyone. On

paper…sometimes we forget to

complete the forms so the patient gets missed. In the EHR,

it is automatic.” WCCHC Staff

Member

“1 in 10 Asians have chronic Hepatitis B, but we are actually

finding in our population it is as

high as 1 in 8, which ends up being almost as common as

hypertension.” CBWCHC Provider

Health information technology helps health centers track enabling services and address patient

needs. Enabling services play a particularly critical role for many underserved, underinsured, and

uninsured individuals. In fact, for some individuals, scheduling the appropriate interpretation services in

conjunction with the clinic visit or even documenting their language needs provides essential information

to make the physician’s instructions fully useful. For instance, ICHS uses their EHR in conjunction with

the enabling services template to help schedule interpreters for patient visits. Through use of the EHR to

track patient needs around non-clinical services such as interpretation or additional education, clinics can

better document the various facets of the care they provide and illustrate the critical importance of these

services for their patients.

The health centers included in this case study adopted different models for delivering enabling services.

For instance, ICHS captures their enabling services through multiple programs including: patient services,

health education, clinic operations (e.g. eligibility workers, medical assistants, health assistants, medical

interpreters, etc.), while CBWCHC does so through their social services department. Regardless of the

model for delivering enabling services, all centers noted the importance of good communication and

consistent information between different kinds of service providers, as well as the importance of

streamlining how they communicate patient needs between health care providers and enabling services

providers. For example, CBWCHC staff discussed how the EHR facilitates tracking their patients referred

for additional social services or non-clinical enabling services and

allows patients to receive such services more efficiently. One

CBWCHC social worker described how the EHR improved his

ability to provide additional services to his patients when referred

by clinicians, stating “Before the EHR… sometimes it would be a

week or so before we saw the actual documentation in front of us on

our desk regarding the patient’s needs. Sometimes it was quite

difficult. With the EHR, it is more simplified and systematic…I think

with the enabling services [integrated into the EHR] it is definitely

helpful. We’re able to capture the information we need in a systematic way to see what our patient needs

are so from that point on we can focus in on helping that patient.” Across all sites, providers and staff

noticed an improved ability to coordinate patient care and enabling services as a result of tracking

enabling services through their EHRs,

Health centers utilize EHRs to address needs that are specific to their unique patient population.

Some of the clinics included as part of this case study use their EHRs to not only track enabling services,

but to also address specific and critical clinical needs of the populations they serve. For example,

providers at CBWCHC noted that some Asian American groups

experience disproportionately high risk of having a chronic

Hepatitis B infection. To address the needs of their patients

afflicted by Hepatitis B, CBWCHC has customized their EHR to

include forms, flow sheets and a registry specific to Hepatitis B.

These customizations allow CBWCHC providers easy access to

information on all of the lab tests and various metrics important to

track for their Hepatitis B patients. One CBWCHC staff member noted how the flow sheet improved

efficiency because they no longer needed to scroll through several documents; the flow sheet provides a

quick and easy way to look at the clinical condition of a patient.



“We definitely wanted to be a data-

driven environment. We just as an

organization are really committed to using data to ensure quality. That is

because we are really interested in changing the health status of the

community.” CBWCHC Administrator

“How technology is going to help is

now we are able to capture [the

enabling services] in a way that we can report it. So now we are not only

capturing the service but we are able to link it and follow this patient of a

course of time or a particular

population to prove what we are seeing in terms of benefitting

outcomes.” CBWCHC Administrator

CBWCHC also developed Hepatitis B care cards for their

patients to help them track information about their disease.

While not electronic, these cards contain information from their

providers on medications, required screenings and lab results,

all elements documented and tracked using the EHR. Patients at CBWCHC extensively discussed their

Hepatitis B care cards, noting the importance of the cards to provide piece of mind about how the center

manages their condition.

Integrating patient and enabling services data assists health center staff with reporting. The

individuals we spoke with from the health centers included in this case study discussed different uses of

their EHRs to report on enabling services, including reports that illustrate the relationship between

enabling services and patient outcomes. While each of the sites uses data in slightly different ways, they

all view their EHR as a critical part of accurately documenting the care and services they provide. For

example, staff at CBWCHC commented on the benefits of using health IT to illustrate the quality of care

at their center: “We always felt like we had the highest quality health care but we didn’t have the tools to

show that. We felt that data was really the way to do that.”

Integrating patient and enabling services data in their EHRs allows reporting on the prevalence of specific

patient needs among the groups served, as well as each site’s attempts to address these needs and the

potential positive impact on patient outcomes. To address the potential impact of enabling services on

patient outcomes, several of the sites we visited as part of this case study take part in another AAPCHO

initiative called the Pacific Innovation Collaborative (PIC). The PIC allows multiple health centers to

submit a subset of their data on enabling services needs and encounters to a single data warehouse,

allowing for comparisons across sites. By examining patient data and outcomes at different sites,

individual clinics can identify specific strategies being employed by other centers that could benefit their

patients. A stakeholder from one of the participating health centers described the PIC as a health registry

data warehouse that aggregates the data from the 9 community health centers involved and two payers.

The PIC uses this data to conduct a cross comparison between the health centers and the populations

within the health centers.

Participating health centers also use data from the PIC to help

illustrate the relationship between services provided and

improved patient outcomes on a broader scale. One health

center representative noted that their clinic uses the PIC reports

for internal use and to determine how they compare to others.

Also, the health center saw an important benefit to

documenting the value of enabling services using the PIC

reports in order to make the case for a different approach to

compensation for these services among third party payers: “We

just gave it a big push to get payers to see what we do and of

course the federal government and CMS to see that it is not just a matter of our providers being efficient,

it is all the other things we do to help our patients to help improve their outcomes.”

Health centers treating AA & NHOPI populations noted the benefits of using EHRs for chronic

disease management and patient education. Staff, patients and providers alike all perceived

significant benefits to case management from tracking enabling services through the EHR and the



“I think the difference is also

dependent on the clinic…We are very good and have developed and fine-

tuned the templates used for capturing interpretation services because of our

population…In Hawaii [at some health

centers], [most patients] speak English, so they have [captured] more

robust outreach and education.” ICHS

relationship between effective case management and improved clinical outcomes especially for patients

with chronic illness. Patients at CBWCHC discussed the importance of non-clinical services received,

including assistance with obtaining health insurance and pharmaceutical coverage. The providers at

CBWCHC provide this information to their patients more systematically than before because they

document it through the EHR. As one provider noted, “We would not be doing a very good job [if we did

not have health IT]. Most of us do not have the capacity to remember to do everything especially if you

have to scroll from document to document. It makes so much sense to put all the data in one place. I can

look at it in a glance and get a really good idea of what I need to do.”

Additionally, many of the individuals we talked to discussed the critical importance of health education

for many AA & NHOPI groups, and the added benefit of using the EHR to track this need. For instance,

one staff member at ICHS described how the EHR target patients who need extra attention such as health

education, which ultimately helps improve disease management. At WCCHC, one administrator

described a study they conducted to determine the impact of health education on hemoglobin A1C for

diabetic patients, noting that those patients receiving enabling services lowered their A1C levels more

quickly than those who did not.

Barriers to Use of Health IT Tools

While this case study illustrates the potential for use of EHR systems to track non-clinical enabling

services provided to underserved populations, we also identified a number of barriers and challenges.

Capturing and documenting enabling services data systematically requires both standardization

and customization. Even though AAPCHO created standardized definitions and categories for enabling

services as part of the ESAP, each clinic spent substantial additional time creating new templates within

their EHRs and building necessary reports to track enabling services and to follow-up with patients.

Standardizing data elements allows for consistent reporting and benchmarking (e.g., using the PIC

warehouse) but each health center developed its own template to reflect their workflow, services and the

needs of the specific populations served. One stakeholder at WCCHC described the need for

customization, saying “part of enabling services is adapting to the Meaningful Use population that you

serve. So you have communities where more translation is necessary because you have different

languages. Even in Hawaii you have different needs based on different geography. For instance a health

center in Honolulu would have a different population than what we have here in the West Coast of the

Island.”

Further, individual health centers found the need to define

their own data elements very specific to their population. For

example, if a center serves a primarily Chinese population

and sees very few patients from other races and ethnicities,

they may benefit from collecting data on which province in

China a patient immigrates from in order to better understand

their risk of historical exposure to certain pathogens. The

same center may not require a standard “ethnicity” field based

on Census definitions which asks to identify patients as

whether or not they are Hispanic: “one example of ludicrousness for us is that we have to collect what

kind of Hispanic group – we had to create a whole other field [in the EHR for it] and for everyone in our

organization it is an extra click that has no meaning for us.” In cases like this, health centers may be able



“We don’t all need to recreate the wheel especially other health

centers. I know a lot of other health centers that want to do the

Hepatitis B work that we do and

they are not able to get their physicians from primary care

mode to gaining that specialized information and a lot of them

really think it is great and want a copy of it, but you can’t just share

the whole thing.” CBWCHC Staff

Member

to overcome the need for additional clicks by applying some logic or pre-populated data to their templates

(e.g., always having “non-Hispanic” checked unless it is actively “un-checked” by staff).

Customization to specific population takes considerable time and resources. As noted earlier,

health centers developed specific templates, flow sheets, and registries to meet staff and patient needs. As

one staff member from ICHS noted, standard templates available through EHR systems do not always

address their needs, so they create their own. Stakeholders at CBWCHC noted it took an estimated 3

months and $20,000 to create their Hepatitis B templates and flow sheets. Additionally, in Hawaii, staff

members worked with each core department to create templates to fit their workflow. One staff member

from WCCHC indicated developing templates for one of their departments took over a year. Due to

already limited resources and staffing, many of these health centers have to pick and choose which

templates they are able to develop. Additionally, many health centers do not have staff with custom

template development expertise and must rely on consultants for this work, adding to the time, cost and

complexity of the activity.

A lot of small community-based clinics focus on the same

chronic diseases; however specific workflow needs and

incompatible EHRs present large barriers to directly sharing

templates between clinics. At WCCHC, for instance, workflow

drives customization of their templates, with one staff member

noting that although all four ESAP clinics collected the same

enabling services codes, each clinic incorporates those codes into

their workflow differently. Incompatibility of technology poses a

challenge; discussants noted that some clinics use pre-built forms

from their EHR vendor while others build needed forms

themselves. As a result, while clinics can share lessons learned,

they still face the need to customize their own templates.

Defining an enabling service and capturing the enabling service poses difficulties. Although

tracking services across health centers requires a somewhat standard definition of enabling services, this

poses challenges for health centers that provide different services under this umbrella or provide similar

services in different ways. As part of the ESAP, AAPCHO developed a standardized definition for an

enabling service as those services provided outside of the regular visit. Therefore, if a service such as

interpretation or health education is provided during the regular visit, it may not be considered an

enabling service– making the definition problematic for some health centers.

Based on these guidelines, many administrators and providers found it difficult to determine when and

how to document particular enabling services. Providers from ICHS and CBWCHC use interpretation and

translation services frequently; they find it especially challenging to document every time they provide

these services. For example, CBWCHC noted that 95% of their encounters involve providing services in a

language other than English; they questioned whether to document all of these encounters for translation

and interpretation. According to enabling services protocol, only registered patients are documented

because the coding is meant to facilitate reimbursement. Also one provider at ICHS described how easily

his community encounters can go undocumented, “That’s one of the challenges of the EHR—everything

that is done in the community; if they are not a patient then it is not captured. It is captured if they are a



“There is a huge discrepancy [in

the reimbursement] but I think the question is more does the cost of

enabling services equate to

patient outcomes. Is the cost we are putting in for enabling services

worth the outcomes we are getting?” WCCHC Administrator

patient and they go to a bon a fide class. If I am talking to people in a community setting, then it is more

information and it does not get documented.”

Policy and Organizational Factors for Replicability

Finally, we present findings related to policy and organizational factors that played an important role in

the implementation and use of health IT in these clinics, particularly as they relate to replicability.

Using health IT systems to document and track enabling services may help health centers make

the case for reimbursement. To best meet the needs of their patient populations, many community

health centers provide enabling services to their patients, knowing these services play a critical role in

improving patient care. In this era of limited budgets, however, many clinics struggle to find the

necessary resources to support the cost of enabling services because they are generally not reimbursable.

One ICHS stakeholder described the challenge: “Enabling services are provided by probably every

FQHC and [are] not [consistently] captured and it is not linked to quality or outcome measures and

[then] there [is] no way to advocate for any kind of reimbursement for services [to funders like] BPHC

or private insurance companies. We are keeping people healthier with these wrap around services, so the

value to the agencies was that we recognized early that we needed a way to articulate that the services we

are providing are helping improve quality and outcomes.”

Since EHRs do not automatically define and capture the broad

range of enabling services provided by community health

centers, the ESAP benefits participating health centers by

providing a way to systematically document these services and

assess their costs and overall impact. One stakeholder from the

KPHC clinic in Hawaii described how the enabling services data

captured in their EHR may ultimately secure grants or payments

from insurance companies as part of advocacy efforts.

Stakeholders from AAPCHO and participating member clinics also intend to use data from the ESAP and

the PIC to make the case for reimbursement to policymakers and funders alike that these services improve

quality and outcomes. Ultimately, a consistent funding stream for these services through reimbursement

would help ensure their sustainability, not only for those health centers included in this case study, but

also for others providing this type of care.

A centralized hub or technical assistance center may help safety net providers find products that

can be adopted or adapted to their unique needs and stretch limited resources. Many community

health centers have limited information about how other centers customize their EHR to address

workflow and patient needs. Many safety net providers do not feel they have a common resource to share

these types of solutions. While off the shelf EHRs do not accommodate basic needs for enabling services,

many of the individuals we spoke with noted the basic system for using an EHR to track enabling services

could certainly be replicated, even if different health centers provide different services. To that end, via

the AAPCHO website, stakeholders can access the standard data elements and methodology for collecting

enabling services data developed as part of the ESAP.xi Further, member clinics also seem willing to share

their experiences and more resources of this kind may support future efforts. As one administrator from

WCCHC said, “The basic template that our health centers use for enabling services – I know we worked

on an agreement with AAPCHO so that it can be shared with other health centers for free. So there is a



Project Background, Data Sources The Office of the National Coordinator for Health IT (ONC)

and the Health Resources and Services Administration

(HRSA) awarded NORC at the University of Chicago a project to conduct case studies examining lessons learned

from community organizations using health IT to serve the needs of underserved groups or to address health

disparities. The final report from this project will inform the

Secretary of HHS’ work under these topics per Section 3001 of the Health Information Technology for Economic and

Clinical Health (HITECH) Act passed as part of the American Recovery and Reinvestment Act of 2009 (ARRA). Findings

are based on analysis of notes taken during a series of discussions with administrators, providers, case managers,

and patients from the following four AAPCHO Enabling

Services Accountability Project sites: (1) International Community Health Services (ICHS) in Seattle, WA;

(2)Charles B. Wang Community Health Center (CBWCHC) in New York, NY; (3) Waianae Coast Comprehensive Health

Center (WCCHC) in Waianae, HI; and (4) Kalihi-Palama

Health Center (KPHC) in Honolulu, HI.

basic enabling services template….which can be shared with other health centers if they ask…we are

more than happy to send screen shots to whoever wants to see what it looks like.”

Many staff also felt they could enhance the replicability and sustainability of efforts such as ESAP with

increased interoperability and more forums for sharing ideas. Staff at CBWCHC specifically highlighted

the potential benefit of sharing methods and processes across health centers. This willingness of health

centers to share ideas, combined with their desire for information from one another, may present a unique

opportunity for creating a centralized database or technical assistance center where small community

providers share their experiences using health information technology to address specific population

needs and health disparities, and may also allow clinics to stretch their limited financial resources.

Summary of Findings

This case study highlights the critical role

health IT systems can play for community

health centers serving low-income, primarily

uninsured and underinsured minority

patients. This case study revealed these

individuals tend to rely heavily on

community health centers for non-clinical

services, or enabling services, in addition to

services relating directly to their health care.

The study revealed the value of both

standardization and customization to

documenting enabling services using EHRs.

This study highlights how tracking enabling

services in a consistent and standardized way

can have a significant positive impact on

patient care and outcomes. Lastly, it also

highlights how individual health centers can

customize their health IT systems to help

address the specific health disparities

experienced by the populations they serve.

Acknowledgements

NORC would like to thank the community health centers that participated in this study.

For more information about AAPCHO’s Enabling Services Accountability Project and Pacific Innovation

Collaborative, please contact Heather Law at [email protected].

i About the ESAP. AAPCHO Current Projects. http://www.aapcho.org/current-projects/enabling-services-

accountability-project/ ii AAPCHO mission as cited on website: http://www.aapcho.org/site/aapcho/ iii AAPCHO About AAPCHO fact sheet. iv AAPCHO 2010 AA & NHOPI fact sheet. Available at

http://www.aapcho.dreamhosters.com/download/PDF/2010AANHOPIfactsheet_FINAL.pdf



v U.S. Census Bureau press release. “Income, Poverty, and Health Insurance Coverage in the United States: 2009.”

Available at http://www.census.gov/newsroom/releases/archives/income_wealth/cb10-144.html vi AAPCHO mission as cited on website: http://www.aapcho.org/site/aapcho/ vii President's Advisory Commission on Asian American and Pacific Islanders. Enhancing the economic potential

of Asian and Pacific Islanders. Washington, DC: The White House; 2007. viii MGMA Center for Research. Health Center Enabling Services: A validation study of the methodology used to

assign a coding structure and relative value units to currently non-billable services. As cited in AAPCHO

publication “Enabling Services at Community Health Centers – A Critical Component in Building Sustainable

Health Care Homes.” Available at http://www.aapcho.dreamhosters.com/download/PDF/AAPCHO-

ES_at_CHCs_Building_Sustainable_Health_Care_Homes-Sep2010.pdf

Chang Weir, R. et al. Use of enabling services by Asian American, Native Hawaiian, and Other Pacific Islander

patients at 4 community health centers. American Journal of Public Health. 2010;100(11):2199-2205. ix Robert Wood Johnson Foundation. Importance of Language Services. Available at

http://www.rwjf.org/files/research/ch1overviewimportanceoflanguageservices.pdf x Center for Health IT at the American Academy of Family Physicians. “Potential Benefits of an EHR.” Available at

http://www.centerforhit.org/online/chit/home/cme-learn/tutorials/ehrcourses/ehr101/benefits.html xi AAPCHO Enabling Services Data Collection Implementation Packet, 2010. Available at

http://www.aapcho.dreamhosters.com/download/PDF/AAPCHO-ES_Implementation_Packet-Oct2010.pdf

Developing an AAPCHO Institutional Review Board (IRB)

The Association of Asian Pacifi c Community Health Organizations (AAPCHO) represents 29 community health organizations across the United States serving over 400,000 patients annually. Our health centers are at the forefront in providing community responsive, fi nancially affordable, culturally profi cient, and linguistically appropriate primary health care services that improve the health status and access for medically underserved AA&NHOPI populations. With the growing research that our member organizations conduct, an Institutional Review Board housed at AAPCHO would be benefi cial to increase capacity for ethical and quality culturally and linguistically appropriate research.

This fact sheet outlines the benefits for developing an Institutional Review Board (IRB) that is specific to ensuring that AAPCHO or member-initiated research is relevant to our members and their communities, has scientific merit, and conforms to high standards of research integrity.

W H AT I S TH E PU R P OS E O F A N A A P C H O I R B A N D H OW D O E S IT

F U N C TI O N ?

AAPCHO would like to establish an IRB to conduct the following:• Build research infrastructure and capacity among members• Empower community programs and partners in the IRB process and to be equal research partners• Engage and educate community programs and partners on importance of IRB• Ensure research is culturally and linguistically appropriate.• Give a voice to under-represented communities in research, especially involving human subjects• Provide guidance for human subjects protection

A coordinator would communicate with and run activities for the IRB. The IRB would ac-cept applications on a quarterly or as need-ed basis for review, and application forms would be available on AAPCHO’s website for download. IRB members would review all new funding applications and renewal re-

quests from member organizations that do not have their own IRB.

H OW W I LL TH E I R B B E M A I NTA I N E D ?

The coordinator in charge of IRB activities would maintain and record all applications, document all processes, coordinate appli-cation review requests, communicate with applicants any necessary steps to take, and provide workshops and TA on research de-sign, methodology, and human subjects pro-tection.

Recruitment of IRB reviewers will come from AAPCHO’s National Research Advi-sory Committee (NRAC), staff or affi liates of AAPCHO’s member organizations, and relevant AAPCHO staff and Board of Direc-tors. Support for the IRB will come from fi nancial grants, minimal application fees, member dues, volunteer participation by IRB members, and in-kind support of efforts and meeting costs.

Due to competing priorities, AAPCHO would accept an average of 5 - 10 applica-tions per year (not including renewals).

FACTSHEET2012

300 Frank H. Ogawa Plaza, Suite 620Oakland, California

W W W. A A P C H O. O R G P 510.272.9536F 510.272.0817

“The use of [academic] IRBs, in my opinion, is a short-term solu-tion. I hope we can advance on AAPCHO’s plans to develop an IRB that would cover CHCs. Otherwise, I think we will keep having to face this issue…With-out such things in place, it does appear like CHCs are viewed more of a recruiting site rather than equal research partners that can house and help ana-lyze research data and subse-quently use research fi ndings

to articulate our messages”.

~ AAPCHO CHC staff

“Having an IRB housed at AAPCHO will put our com-munity health centers in the driver’s seat, so that we can do the work that fits with our mis-sion and values independent of academic institutions. We can be the applicant organization in charge of our own budget without most of the funding going directly to the academic institutions who usually have unusually high indirect rates.”

~ AAPCHO CHC staff

USE F U L R E SOU RC E S

Here are a few resources that you can look up for further information about Institutional Review Boards.

Selected articles on community IRBs and building community research capacity:• Navajo nation IRB: a unique human research review board has three primary concerns:protecting its community, its people, and its heritage. Prot Hum Subj. 2003 Spring;(8):1-2. http://www.science.doe.gov/ober/humsubj/spring03.pdf • Braun KL, Tsark JU, Santos L, Aitaoto N, Chong C. Building Native Hawaiian capacity in cancer research and programming. A legacy of ‘Imi Hale. Cancer. 2006 Oct 15;107(8 Suppl):2082-90.• Brugge D, Missaghian M. Protecting the Navajo People through tribal regulation of research. Sci Eng Ethics. 2006 Jul;12(3):491-507.• Colwell-Chanthaphonh C. Self-governance, self-representation, self-determination and the questions of research ethics--commentary on “Protecting the Navajo People through tribal regulation of research”. Sci Eng Ethics. 2006 Jul;12(3):508-10.• Hernandez JAA. Blood, lies, and Indian rights: tribal colleges and unitiversities (TCUs) be coming gatekeepers for research. 2004; 16(2). http://tribalcollegejournal.org/themag/backis sues/winter2004/winter2004hernandez.html• Kagawa-Singer M, Park Tanjasiri S, Lee SW, Foo MA, Ngoc Nguyen TU, Tran JH, Valdez A. Breast and cervical cancer control among Pacifi c Islander and Southeast Asian Women: participatory action research strategies for baseline data collection in California. J Cancer Educ. 2006 Spring;21(1 Suppl):S53-60. http://www.leaonline.com/doi/pdf/10.1207/ s15430154jce2101s_11• Oneha MF; Beckham S. Re-examining community based research protocols. Pacifi c Public Health 2.11:1;2004.• Schrag B. Research with groups: group rights, group consent, and collaborative research commentary on “Protecting the Navajo People through tribal regulation of research”. Sci Eng Ethics. 2006 Jul;12(3):511-21.

T E R M I N O L O G Y

INSTITUTIONAL REVIEW BOARD (IRB): A committee designated to approve, monitor, and review research involving human subjects. IRB approval is required before undertaking research mandated by the federal government.

B E N E F I T S

• Increased capacity by AAPCHO and member CHCs to conduct research• AAPCHO’s member communities would hold ownership of the data• AAPCHO would serve as conduit to provide oversight on human protections• Member organizations become more aware of IRB process• Empowerment of communities’ role in IRB process

M O R E I N F O R M AT I O N

For more information, please contact Director of Research Rosy Chang Weir, PhD at [email protected].

Selected examples of independent community IRBs:• Special Service for Groups (http://www.ssgmain.org/) and the Orange County Asian Pacifi c Islander Community Alliance (http://www.ocapica.org) co-founded and developed a community-based Institutional Review Board (IRB) in Los Angeles, California. A broad group of community-based organizations and community leaders support the IRB and serve in several capacities, such as IRB members. About the IRB: http://www.cbcrp.org/publica tions/newsletters/2006/page_17.php • Waianae Coast Comprehensive Health Center research and IRB policies/procedures: www. wcchc.com.• American Public Health Association conference audio-recorded presentation: A community perspective of CBPR methods: The Promoting Access to Health for Pacifi c Islander and Southeast Asian women program: http://apha.confex.com/apha/134am/techprogram/pa per_131797.htm• Papa Ola Lokahi: http://www.papaolalokahi.org: Native Hawaiian Health Care System (NHHCS) – Institutional Review Board (IRB): http://www.papaolalokahi.org/hoe2/index. cfm?wwa_ID=93B99296-EF41-4D27-9ECEB62C082DD382&sub=yes• Navajo Nation Human Research Review Board: http://www.nnhrrb.navajo.org/

National resource:• Offi ce for Human Research Protection [OHRP] is a major resource of the federal government: http://www.hhs.gov/ohrp/

“Meaningful Use” & AAPCHO’s HIT Programs The American Recovery and Reinvestment Act (ARRA) of 2009, among other things promotes the “mean-

ingful use” of electronic health records (EHRs) as a way to improve the quality, effi ciency, delivery, and af-

fordability of health care. As the overseer of this program, the Centers for Medicare and Medicaid Services

(CMS) is promoting the “meaningful use” of certifi ed-EHRs through incentive payments to providers who

“adopt, implement, or upgrade” an EHR system beginning in 2011. Physicians at Federally Qualifi ed Health

Centers (FQHCs) are eligible for this benefi t as these health clinics serve a high proportion of Medicaid

patients.

Providers can use EHR data to improve their ef-

fi ciency. For example, the number of steps involved

in the medication prescription process is reduced

if a physician can electronically send a patient’s

prescription to a pharmacy directly, rather than have

the patient hand-deliver that prescription and wait

for it. By and large, providers must fulfi ll a host of

“meaningful use” requirements using an approved

and certifi ed-EHR system, such as recording

patient demographics, vital signs and immunization

data.

T H E I M PAC T O F “ M E A N I N G F U L U S E ”

CMS provides up to $27 billion in incentives

through Medicare and Medicaid to providers that

adopt, implement, upgrade, or demonstrate “mean-

ingful use” of certifi ed-EHR technology. Federally

Qualifi ed Health Centers (FQHCs) are eligible

for these funds as they predominantly serve low-

income and uninsured patient populations. Eligible

FQHC physicians can apply for state incentive

payments of up to $63,750 over six years, and up to

$21,250 in the fi rst year for simply using a certifi ed-

EHR system. The hope is that “meaningful use” of

electronic data will lead health centers to better

clinical decisions and improved health outcomes

(see Figure 2).

H I T T E R M I N O L O G Y

E LEC TRON IC H E ALTH

R ECOR DS ( E H R S )

A longitudinal collection of electronic health information that serves as a legal medical record for patients or populations, which can include demographics, vital signs, lab assessments, immunization records, and billing information.

E LEC TRON IC PR E SC R I B I N G

E-prescribing describes medications that are electronically entered and transmitted by prescriber directly to a pharmacy.

H E ALTH I N FOR M ATION

TEC H NOLOGY ( H IT )

Technology and tools used to maintain health information in an electronic format.

M E AN I N G F U L USE

The use of Electronic Health Records (EHRs) by providers to achieve signifi cant improvements in care.


For more information about the PIC Project, please contact Research Associate Heather Law, MA at [email protected]

Figure 1. “Meaningful Use” policy is designed with the intent of reducing health disparities,

improving population health, and building a better health care infrastructure for all Americans.

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Figure 2. Conceptual Approach to “Meaningful Use”

W H AT I S “ M E A N I N G F U L U S E ” ?

“Meaningful Use” is broadly defi ned as a provider’s

ability to use certifi ed-EHR technology in a way that

assesses the level and quality of care that is be-

ing delivered. “Meaningful use” practices, such as

e-Prescribing and electronic appointment reminders,

help assess quality improvement. The electronic col-

lection of this data helps improve clinical processes

and decision-making on behalf of a patient, and leads

to greater coordination of care and patient/provider

communication.

Standards are still evolving for both compliance of

meaningful use”, and the nationwide adoption and

utilization of EHRs. The fi rst stage of “meaningful

use” focuses on a provider’s ability to collect patient

data electronically and use that information for key

clinical decisions and provider performance evaluation

purposes.

“ M E A N I N G F U L U S E ” & A A P C H O ’ S H E A LT H I N F O R M AT I O N

T E C H N O LO GY ( H I T ) P R O G R A M S

“Meaningful use” can prove valuable to medically underserved Asian American,

Native Hawaiian, and other Pacifi c Islanders (AA&NHOPI) and the provid-

ers that serve them. Many of these individuals, who are of low socioeconomic

and poor health status, are served at FQHCs in AAPCHO’s Pacifi c Innovation

Health Information Technology Network project, and many FQHC physicians

are eligible for incentive payments. The HIT programs aim to utilize FQHCs’

technological capacity to improve the quality and cost-effectiveness of health

care to low income, high-risk and underserved patients. By utilizing technology

effectively and effi ciently, AAPCHO’s network of providers is poised to meet the

“meaningful use” objectives and apply for Medicaid EHR incentive payments.

AAPCHO’s HIT programs currently incorporate requirements under “meaningful

use” (see Table 1). In general, the PIC project programs ensure that FQHCs

can integrate EHR and comply with “meaningful use” standards:

F U T U R E I M P LI C AT I O N S

“Meaningful Use” incentivizes providers to be more knowledgeable and equipped

to access a patient’s medical history via EHRs. Such emphasis on health informa-

tion technology can lead to improved population health. In moving forward with

“meaningful use” policy, health care providers, patients, and other stakeholders

should take note of the following:

• Adopting and demonstrating the use of certified-EHRs is time consuming and

requires adequate funding, staffing, and support.

• Implementing certified-EHR technology across a network of health care provid-

ers can lead to the national goal of achieving a Health Information Exchange (HIE).

• Sharing patient health information and exchanging best practices can promote

partnerships between providers/hospitals and the public health sector.

• The HITECH Act’s Medicare and Medicaid EHR incentive payments are avail-

able to eligible providers and hospitals starting in 2011. Resources and technical

assistance are provided, but the incentive program ends in 2015.

• Maintaining awareness of current government policies & program changes can

ensure compliance under “meaningful use.”

For background reading on “meaningful use” policy, reference:

1. Blumenthal, D. and M. Tavenner (2010). “The Meaningful Use Regulation for Electronic Health Records.” New England Journal of Medicine. 363(6): 501-504.

2. Finnegan, B., L. Ku, P. Shin, and S. Rosenbaum. “Boosting Health Information Technology in

Medicaid: The Potential Effect of the American Recovery and Reinvestment Act.” Geiger Gibson/RCHN Community Health Foundation Research Collaborative Policy Research Brief No. 9. Washington, DC: July 7, 2009. Available at http://www.gwumc.edu/sphhs

For more information on HIT and “meaningful use,” visit the following websites:

1. Centers for Medicare and Medicaid Services (CMS). “Meaningful Use” website at https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp

2. U.S. Department of Health and Human Services (HHS). Health Information Technology website at http://healthit.hhs.gov

REFERENCE S

1. The “Pacifi c Innovation Collaborative Health Information Technology” (PIC) project utilizes interoperable EHR software to reduce health

disparities by improving the safety, quality, effi ciency and effectiveness of health care delivery.

2. The “Incentivizing the Outcome: Paying for Population Health at FQHCs in Hawaii” (P4P) project focuses on the reduction in health dispari-

ties for AA&NHOPI high-risk populations through team-based and culturally competent care.

3. The “Enabling Services Health Information Exchange at Hawaii Health Centers” (PIC ES) project aims to integrate culturally appropriate

enabling services to evaluate their quality and performance impact on clinical health measures (i.e. diabetes).

Table 1. “Meaningful Use” Objectives and AAPCHO’s HIT Programs

The Pacific Innovation Collaborative (PIC)The Pacific Innovation Collaborative Health Information Technology Project is a Department of Health

& Human Services Health Resources and Services Administration funded network of eight community

health centers and two health plans in Hawaii and Washington. The intent of the network is to design and

develop an electronic infrastructure for community health centers in separate states to exchange patient

information based on performance measures important to the network. The overall aim is to utilize

eletronical medical record systems to reduce health disparities by improving the safety, quality, efficiency

and effectiveness of health care delivery.

P R o j e C T PA R T n e R S

Federally Qualified Health Centers

• CommunityHealthCentersofKingCounty

(CHCKC)

• Healthpoint

• FamilyHealthCenters(FHC)

• InternationalCommunityHealthServices(ICHS)

• Kalihi-PalamaHealthCenter(KPHC)

• NeighborCareHealth

• WaianaeCoastComprehensiveHealthCenter

(WCCHC)

• WaimanaloHealthCenter(WHC)

Health Plans

• AlohaCare

• CommunityHealthPlanofWashington(CHPW)

Regional Aggregation Sites

• HawaiiPatientAccountingServices(HPAS)

• PTSOofWashington

P R o j e C T Y e A R S

The project is comprised of four phases:

• Phase1:Planning/Testing(2007-08)

• Phase2:ExpansionofInfrastructure(2008-09)

• Phase3:Implementation(2008-10)

• Phase4:FinalEvaluation&Review(2010-11)

H e A lT H I n F o R m AT I o n T e C H n o l o g Y ( H I T )

HealthInformationTechnology(HIT)referstoawide

variety of computer applications, which includes elec-

tronic medical, health, and dental record systems, patient

portals, personal health records, chronic disease manage-

mentsystems,datawarehouse/reportingsystems,and

digital imaging systems, to name a few.

Through the PIC project, AAPCHo has created a

data repository, in which project members share

data and provide technical assistance and facilita-

tionofsharedcaremanagement(team-based

care).Thisdatarepositoryhelpsimprovecom-

munication between providers and their patients

and is believed to improve individual health center

performance.

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P e R F o R m A n C e m e A S u R e S A n D T H e P I C R e P o S I T o R Y

With improving health center performance in mind, project members carefully chose

measures to track through a combination of claims, practice management system,

andelectronichealthrecorddata[Table1].Fromahealthcenterperspective,these

measures,bothclinicalandprocess-based,wereselectedtohaveanimpactonthe

timeliness; effectiveness; efficiency; and the safety, risk management, and quality of

care provided to patients.

PIC Measures

1.Patientswith4DTaP,3OPV/IPV,1MMR,3HepB,3Hib,andVaricellavaccinationsbyagetwo

2a.PatientswitheitherType1orType2DiabeteswhoseHbA1cis>9

2b.Diabeticpatientswithabehavioralhealth(mentalhealthorsubstance)diagnosiswhoseHbA1cis>9

3a.Patientslessthansevenyearsoldwhohavehadaprimarycarevisitwithinthelast12months

3b.Patientsgreaterthansixyearsoldwhohavehadaprimarycarevisitwithinthelast24months

3c.Thirdnextavailableappointment

4a.PatientsseenintheERwithlowcomplexityproblems

4b.PatientsseenintheERwhofollowupwithprimarycare

5.Patientswithwell-childvisits:(a)inthefirst15months,(b)at3-6yearsold,(c)at12-21yearsold

6.Patientsforwhomearlynotificationofpregnancywasmadetothehealthplan

Table1

P e R F o R m A n C e m e A S u R e S A n D T H e P I C R e P o S I T o R Y ( C o n T. )

TrackingthesixmeasuresoutlinedinTable1wouldallowprojectsitesto

improve on overall health center performance and provision of care. For

example,capturingdataforpatientswithType1orType2Diabeteswhose

hemoglobinlevelsaregreaterthan9%(Measure2a)wouldallowahealth

center to better track the progress of these patients over time, and tailor its

diabetes management strategies to improve its patients’ health outcomes.

once collected, process measure data from all sites are sent to regional

database repositories in oahu, Hawaii and Seattle, Washington. AAPCHo

serves as the project’s central repository, electronically collecting data from

theregionaldatabases[Figure1].Thecentralrepositoryaggregatesclinical

information and provides reports for all project sites to view and share.

P I C DASHBOARD

APICcomparativedashboard[Figure2]wascreatedasauser-friendlysummaryreport

ofaggregatedataforthemeasureslistedinTable1.Thedashboardwasdevelopedas

a model for project health centers to view this data across multiple health centers. It

enables users to view trend analysis and is beneficial for the future development of HIT

activities,suchasAAPCHO’sPay-for-PerformanceandEnablingServicesHITprojects.

P R o j e C T I m PA C T

The PIC HIT network is a Health Center Controlled net¬work. The creation of this network has provided the op¬portunity for project health centers

to optimize limited resources to share HIT models and practices. The hope is that by building infrastructure to share and exchange HIT, project health

centers can utilize this technology to provide better quality care for their patient populations.

• For more information, please contact Research Associate Heather law, mA at [email protected]. You may also visit the PIC web page at http://research.aapcho.org.

• For information about utilizing and opitmizing HIT at health centers, reference moore, R., Rachman,F.D.,Lardiere,M.R.(2010).Usinghealth information technology to improve quality. Health Center Controlled network SeriesInformationBulletin,15,14.

• For more information and opportunities for implementing and utilizing HIT, visit the following websites:

1. office of the national Coordinator for Health InformationTechnologywebsiteathttp://healthit.hhs.gov.

2. Agency for Healthcare Research and Qual¬ity NationalResourceCenterHITwebsiteathttp://healthit.ahrq.gov

3. Health Resources and Services Administration

Health Information Technology website at http://www.hrsa.gov/healthit/

4. national Association of Community Health CentersHITwebpageathttp://www.nachc.com/HealthInformationTechnologies(HIT).cfm

RE FE RE NCE S

Figure1

Figure2-AsampleclipofthedashboardoutlinesHEDIS

wellchildvisitsforpatientsin(a)thefirst15months,(b)

at3to6years,and(c)at12to21yearsfromJanuaryto

June2008.(Datadownloaded10-11-10)

Enabling Services Health Information Exchange at Hawaii Community Health Centers—Pacific Innovation Collaborative Enabling Services Project

The Pacifi c Innovation Collaborative Enabling Services (PIC ES) Project utilizes elec-tronically collected patient health information to determine if enabling services improves health outcomes for patients living with diabetes.

The project, funded by the Department of Health & Human Services Health Resources and Services Administration, is a partnership between three Hawaii community health centers (CHCs), a Hawaii-based health insurance plan, and AAPCHO. The PIC ES project allows project sites to monitor enabling services, or non-clinical

services such as case management assessment, outreach, translation and transportation, and determine if these services improve the health of patients living with Type 1 or Type 2 diabetes.1 Recent studies suggest that enabling services are critical in improving health outcomes. Enabling services however, though provided by community health centers daily are typically not recorded or evaluated, and therefore are typically under-funded if funded at all.

Through an electronic patient monitoring system and newly developed decision support tool, clinic and enabling support staff at each project site can readily access a patient’s medical record, as well as review the overall steps and processes required in helping the patient manage his/her diabetes. Prior to this electronic patient monitoring system, providers often maintained hardcopy fi les that were not centralized or easily monitored.

Key features of the decision support tool include: 1.) reports indicating a patient need (e.g. medication; follow-up appointment with a specialist, etc.); 2.) a decision support tree, or fl ow chart that allows staff to monitor its processes and steps in managing a patient’s diabetes and care; and 3.) automatic alerts.

1 For a full list of definitions, visit AAPCHO’s website at http://enablingservices.aapcho.org.

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PROJ EC T YE ARSThe project consists of four phases spanning two years:

• Phase 1: Planning (June - December 2010)• Phase 2: Infrastructure Building (January - February 2011)• Phase 3: Implementation (March - August 2011)• Phase 4: Evaluation (September 2011 - May 2012)

PROJ EC T M E A SU R E S

The PIC ES project examines enabling services provided to patients with either Type 1 or Type 2 diabetes in the following areas:

• Case Management Assessment• Case Management Treatment• Case Management Referral• Eligibility Assistance/Financial Counseling• Health Education/Supportive Counseling• Interpretation• Outreach• Transportation

For a full list of definitions, visit AAPCHO’s website at http://enablingservices.aapcho.org.

PROJ EC T IM PAC T• More effective and efficient delivery of health care through physician/patient reminders, alerts, and reports.• Quicker provider response time. • More comprehensive and timely monitoring of patient status and provider processes.• More effective tracking of enabling services.• Increased health center capacity to implement and integrate Health Information Technology and Electronic Health Records.

P ROJ E C T N E T WO R K

• AlohaCare (Honolulu, HI)

• AAPCHO (Oakland, CA)

• Kalihi-Palama Health Center

(Honolulu, HI)

• Waianae Coast Comprehensive

Health Center (Waianae, HI)

• Waimanalo Health Center

(Waimanalo, HI)

A A P C H O R E SO U RC E S

For further information AAPCHO’s re-

search on enabling services and health

information technology, refer to the re-

sources below. These resources can be

found on the AAPCHO website at www.

aapcho.org.

• “Enabling Services at Community

Health Centers - A Critical Compo-

nent in Building Sustainable Health

Homes” (2010)

• “Highlighting the Role of En-

abling Services at Community Health

Centers: Collecting Data to Support

Service Expansion & Enhanced Fund-

ing” (2010)

• “Impact of Enabling Services

Utilization on Health Outcomes” Fact

Sheet (2009)

• “Pacific Innovation Collaborative

(PIC)” Fact Sheet (2011)

• “Incentivizing the Outcome: Pay-

ing for Population Health at Hawaii

Federally Qualified Health Centers”

Pay-for-Performance Project Fact

Sheet (2011)

For more information, contact Research Associate, Heather Law, MA at [email protected]. You may also visit the PIC ES web page at http://research.aapcho.org.

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2011

Incentivizing the Outcome: Paying for Population Health at Hawaii Federally Qualified Health Centers —Pay-For-Performance Project

AAPCHO’s “Incentivizing the Outcome: Paying for Population Health at Hawaii Federally Qualified

Health Centers” Project, also known as the Pay-for-Performance (P4P) Project, is funded by the Rob-

ert Wood Johnson Foundation. With a network of four Federally Qualified Health Centers (FQHCs)

and one health plan located in Hawaii, the intent of the project is to examine whether a team-level

P4P incentive program improves health outcomes, emergency room, and hospitalization measures

for low-income Asian American & Native Hawaiian and Other Pacific Islander (AA&NHOPI) popula-

tions served by FQHCs.

A B O U T PAY- F O R - P E R F O R M A N C E

The project’s Pay-for-Performance (P4P) model is based on monetary incentives that are

provided to health centers from health plans. In this program model, the health plan

rewards health centers who meet pre-determined performance measures (e.g. lowering

HbA1c levels) and in effect, improve the quality of care and deliver more efficient services

to their patients. Team-based P4P rewards health center teams which consist of physi-

cians and enabling services providers, such as medical assistants, interpreters, and case

managers.

P R O J E C T g O A l s A N d O B J E C T I v E s

AAPCHO’s Pay-for-Performance Project aims to help health centers assess the effective-

ness of P4P incentives on health outcomes for a low-income AA&NHOPI population

served by FQHCs.

P R O J E C T PA R T N E R s

• AlohaCare(Honolulu)

• BayClinic,Inc.(Hilo)

• Kalihi-PalamaHealthCenter(Honolulu)

• WaianaeCoastComprehensiveHealthCenter(Waianae)

• WaimanaloHealthCenter(Waimanalo)

P R O J E C T Y E A R s

The project consists of five phases spanning three years:

• Phase1:Planning(January-June2009)

• Phase2:DataCollection1(July-December2009)

• Phase3:DataCollection2(January-June2010)

• Phase4:DataCollection3(July-December2010)

• Phase5:Evaluation(January-November2011)

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P R O J E C T M E A s U R E s

The Pay-for-Performance (P4P) Project will clarify the important role of P4P in

improving the health outcomes of high-risk populations with multiple conditions,

such as diabetes and psychosocial conditions.

Pro jec t me asure s inc lude :

• AveragehemoglobinA1c(HbA1c)values

• Numberofpatientsvisitingtheemergencyroomformild/acuteproblems,witha

FederalPovertyLevel(FPL)≥200%andhavediabetesorcardiovasculardisease

and a psychosocial condition

• NumberofpatientswithaFPL≥200%,whowerehospitalizedfordiabetesor

cardiovascular disease and a psychosocial condition

These measures were selected by project partners to evaluate the impact of P4P on the

quality and efficiency of care provided to low-income AA&NHOPI patients with multiple

conditions. If the project incentives are effective in improving diabetes outcomes and

patient utilization of ER visits and hospitalizations, project sites plan to expand on Pay-

for-Performance methods for other measures of care for their patient populations.

P R O J E C T d E l I v E R A B l E s

A N d O U T C O M E s

L oc a l l eve l

• Improvedhealthstatusofthetarget,

high-risk AA&NHOPI population

• Improvedqualityofcareprovidedat

project FQHCs National level

• Contributiontothelimitedresearch

and data about P4P incentives and

the implications for low-income

AA&NHOPI populations

• Demonstrationofqualityimprove-

ment in P4P incentive programs

• Promotionofateam-focused

culturally and linguistically appro-

priate model of care

• Increasedknowledgeofoutcome

and utilization measures, which are

incentivized through a team-level

strategy

For more information, contact Research Associate, Heather law, MA at [email protected]. YoumayalsovisittheP4Pwebpageathttp://research.aapcho.org.

An Analysis of AAPCHO Community Health Centers: UDS 2010Since 1987, the Association of Asian Pacifi c Community Health Organizations (AAPCHO), a national, not-for-profi t organization has represented community health centers (CHCs) that provide quality, comprehen-sive health services that are fi nancially affordable, linguistically accessible and culturally appropriate for Asian Americans, Native Hawaiians, and other Pacifi c Islanders (AA&NHOPIs). AAPCHO’s 29 community-based organizations promote advocacy, collaboration, and leadership that improve health status and access for medically underserved AA&NHOPIs. AAPCHO member CHCs provide services that are uniquely ap-propriate to their patient populations, including: • Culturally and linguistically appropriate health care services• Comprehensive primary medical care including internal medicine, prenatal care, pediatric, nutrition, nursing, pharmaceuticals, optometry, dentistry, and Enabling Services (ES)• Services in numerous languages and dialects including Cantonese, Hawaiian, Ilocano, Korean, Mandarin, Samoan, Tagalog and Vietnamese

A A P C H O M E M B E R D E M O G R A P H I C S

In 2010, AAPCHO served over 380,000 patients at federally qualifi ed health centers. AA&NHOPI pa-tients accounted for 65% of those served.

and other community health organizations. This fact sheet examines only FQHCs who report data to the Bureau of Primary Health Care Uni-form Data Systems (UDS). AAPCHO currently serves 21 FQHCs, up from 12 in 2000.

TOTA L A A P C H O PATI E N T S , 20 0 0 - 2010 The total number of patients served increased 167% between 2000 and 2010. AAPCHO’s average number of patients per site increased 66% in the same period.

T E R M I N O L O G Y

ASIAN Refers to people having origins in any of the original peoples of the Far East, Southeast Asia, and Indian subcontinent.

PACIFIC ISL ANDER Refers to people having origins in any of the original peoples of Guam, Samoa, or other Pacifi c Islands.

NATIVE HAWAIIANSRefers to those persons with native origins in the original peoples of Hawaii.

WHITERefers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa.


For more information, please contact Director of Research Rosy Chang Weir, PhD at [email protected].

FACTSHEET2012


W W W. A A P C H O. O R G T 510.272.9536F 510.272.0817

Pacifi c Islander 7.3%

27,645Asian51.6%196,365

Mixed1.8%

6,830

Native Hawaiian6.9%26,113

Unreported8.9%

33,835

White16.2%61,815

Black or African American6.8%

25,823

American Indian / Alaska Native

0.6%2,139

A A P C H O FQ H C S , 20 0 0 - 2010

AAPCHO’s membership includes federally quali-fi ed health centers (FQHCs), FQHC look-alikes,

AV E R AG E A A P C H O A A & N H O P I PATI E N T S

The average number of AA&NHOPI patients served in-creased 33% between 2000 and 2010.

H OW A A P C H O C E N TE R S CO M PA R E N ATI O N A LLY

AAPCHO member CHC patient demo-graphics and services differ from the av-erage national health center. For example, AAPCHO serves a:• Higher proportion of patients best served in a language other than English (50.3% vs. 24.3%)• Higher proportion of Medicaid patients (41.7% vs. 38.5%)• Higher proportion of geriatric patients (age 65+) (9.3% vs. 6.8)• Higher proportion of non-white patients (74.9% vs. 28.7%)• Higher proportion of patients with

incomes 200% and below the Federal Poverty Level (76.3% vs. 71.2%) • Higher proportion of patients with controlled blood pressure (65.8% vs. 61.8%)

S U M M A RY O F A A P C H O D E M O G R A P H I C S FO R 2010

AAPCHO’s members are geographically located across the country in eight states and one freely associated state. Our 21 member FQHCs serve a unique subset of our nation’s population.• 380,565 total patients served• 84% racial/ethnic minorities,

including 196,365 (51.6%) Asians, 26,113 (6.9%)Native Hawaiians, and 27,645 (7.1%) other Pacifi c Islanders• 50% patients served in a language other than English (191,568)• 62% patients with incomes at or below 100% Federal Poverty level (235,905)• 35% uninsured patients (131,810)• 42% Medicaid patients (158,875)

Source for all data: BPHC UDS 2000 - 2010

L I M ITE D E N G LI S H P RO F I C I E N T ( LE P ) PATI E N T S , 20 0 0 - 2010

In 2010, approximately half of AAPCHO member CHC pa-tients were best served in a language other than English; in-dividual AAPCHO members served as high as 99% LEP pa-tients. The number of LEP patients served increased 152% between 2000 and 2010.

U N I N S U R E D PATI E N T S , 20 0 0 - 2010

The number of uninsured AAPCHO member CHC patients increased 173% between 2000 and 2010. However, the per-centage of uninsured patients has remained steady nationally at about 40%.

a a p c h oAssociation Of Asian Pacific Community Health Organizations

300 Frank H. Ogawa Plaza, Suite 620 Oakland, CA 94612p 510.272.9536 f 510.272.0817

www.aapcho.org

Negotiated Rulemaking Committee (NRMC) on the Designation of Medically UnderservedPopulations and Health Professional Shortage Areas

Summary of Recommendations

Purpose of the Committee The NRMC was established in July 2010 to reexamine the methodology that designates

areas and populations experiencing medical underservice and/or health professionalshortages. The committee was charged to do so using a negotiated rulemaking process.A negotiated rulemaking process convenes key stakeholders in hopes that a federaladvisory committee will reach a consensus on development of new rules or regulations.

On October 31, 2011, the NRMC submitted its final report to the Secretary of Health andHuman Services; although it did not reach a full consensus, 90 percent of the membersvoted to endorse the full package of recommendations (21 to 2 in favor ofendorsement; five members absent).

Individual votes were taken on each of the six types of designations:

1) Geographic Health Professional Shortage Area (HPSA) – geographic HPSA is anarea in which there is a significant shortage of health care providers relative tothe patient population.

2) Population Group HPSA – population group HPSA is modeled after geographicprimary care HPSA with a lower population-to-provide threshold ratio and anautomatic designation for American Indians and Alaska Natives.

3) Facility HPSA (unanimously endorsed) – facilities are Federal or State correctionalinstitutions and public/non-profit medical providers serving designatedpopulation group HPSA’s.

4) Medically Underserved Area (MUA) – MUA’s are currently comprised of fouridentifying components including ratio of primary care physicians to population,infant mortality rate, percent of the population age 65 and over, and percent ofpopulation with incomes below the poverty level.

5) Medically Underserved Population (MUP) - MUP is “the population of an urbanor rural area designated by the Secretary as an area with a shortage of personalhealth services, or a population group designated by the Secretary as having ashortage of such services”; and

6) Exceptionally Medically Underserved Population (EMUP) (unanimously endorsed)– EMUP’s are defined as demonstrating unusual local conditions with respect toaccess barriers that are not covered under the regular MUA/P criteria.

Since the committee did not reach full consensus, the Secretary is not required toimplement the recommendations, particularly those recommendations/sections of thereport that were not unanimously endorsed (see above).

Highlights of Recommendations and Implications for Asian Americans, Native Hawaiians, andOther Pacific Islanders

New criteria were developed, that if implemented, will have implications forunderserved Asian American, Native Hawaiian, and Other Pacific Islander (AA andNHOPI) community organizations and their eligibility level to access the Health CenterProgram funding. These include (but are not limited to) new designationcriteria/methodologies for determining eligibility as an MUA and MUP.

The four components for determining eligibility as an MUA and/or MUP are healthstatus, availability of health professionals, access barriers to care, and ability to pay. Forboth MUA and MUP, new criteria for the access barriers to care component includepercent of the population with limited English proficiency and percent of the populationthat is of a non-white racial group, both of which are unique characteristics of AA andNHOPI populations.

Additionally, to determine eligibility as an MUP and population-group HPSA, populationgroups now eligible include those widely recognized by national reports such as HealthyPeople 2020, to experience health disparities. These include low income and Medicaidpopulations; individuals with limited English proficiency; people with HIV infection;people with physical, sensory, cognitive, or developmental disabilities; Native Hawaiians;LGBT populations; and immigrants and refugees.

The Committee also addressed new pathways for designation of facility HPSA’s. Thecriteria include facilities that function as magnet clinics, safety-net clinics, and serve asthe essential primary care provider in their communities. Magnet clinics are particularlyapplicable to many current Federally Qualified Health Centers and health careorganizations serving AA and NHOPI communities. They are facilities that tend to servecommunities beyond their immediate geographic areas, attracting patients who travellong distances to receive culturally sensitive care. Additionally, a magnet clinic isdefined as “one where more than 50 percent of encounters are provided by primarycare clinicians to one or two populations groups nationally recognized as experiencinghealth disparities”.

The Committee’s recommendations, including new criteria to define MUA, MUP, andFacility HPSA’s, if accepted in the final rule, will have significant implications fororganizations serving AA and NHOPI communities. A considerable number ofunderserved AA and NHOPI patients are limited-English proficient (approximately 39%aggregated), experience great disparities in health conditions including chronic hepatitisB and diabetes, and tend to travel far distances to receive culturally and linguisticallycompetent health care. The revised rules if implemented could greatly increase accessto care culturally and linguistically competent care for AA and NHOPI communitiesacross the country.

Next Steps The Committee unanimously recommended that the Secretary establish an Advisory

Committee to conduct further analyses of the recommendations in order to determinethe final proposed rule.

Opposing Views of NRMC Members A majority of the Committee members noted that the basis on which the

recommendations were developed was solely to define methodologies and designationcriteria for all areas of underservice and shortage of health professionals that whenapplied, would transcend any level of available resources or point in time. Additionally,members did not consider allocation of current resources in determination ofdesignation criteria given that it is a separate process normally carried out by HRSA andnot the responsibility of the Committee.

Two Committee members who did not endorse the full package of recommendationsexpressed their concerns primarily about the designation of too many areas andpersons, which includes the MUA designation threshold level of 33 percent. Theirargument was these expanded designations would create more competition for limitedfederal resources. Additionally, they note that areas with more resources will have thecapacity to assemble data and thus, develop better applications. They ask for furtheranalyses of the methodologies and thresholds for MUAs, MUPs, and HPSAs.

Resources The final report is available at:

http://www.hrsa.gov/advisorycommittees/shortage/nrmcfinalreport.pdf More information on the NRMC is available at

http://www.hrsa.gov/advisorycommittees/shortage/index.html.

Accountable Care in the Safety Net

Terry Conway, MD, Managing Principal & Pat Terrell, Managing Principal

Prepared for the Blue Shield of California Foundation

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Abstract Accountable Care has emerged as a critical delivery system redesign companion to expanded coverage within federal health reform. Accountable Care calls for providers to organize to provide a full continuum of care to patients and populations, to commit to improving quality while controlling cost, and to be rewarded as they succeed. However, the principles of Accountable Care are based upon demonstrations and lessons learned primarily in Medicare populations served by highly organized and integrated health systems. The Safety Net differs in the patient populations it serves, the structures and relationships between its providers, and its funding, which is mainly concentrated in Medicaid and local government reimbursement. Thus, the federal emphasis on the development of Accountable Care will need to be tailored differently for the Safety Net. Further, California’s Safety Net will face the challenges of building collaborative delivery models earlier than the rest of the nation as the renewal of the State’s 1115 Medicaid Waiver is implemented during the next year. These State and national moves toward integrated care offer both opportunity and challenge to the Safety Net and progress toward Accountable Care will be made only after embarking on an honest and thorough examination of necessary changes in relationships and organization, delivery system design, infrastructure, and revenue distribution. Taking leadership now to create Accountable Care is a strategy that is most likely to secure the ongoing existence of Safety Net providers, assure access for the patients they have historically served, and improve the health status of their communities. It is also a strategy that is likely to gain the support of the federal government as new models are sought to efficiently and effectively deliver care for a population that will soon represent the single largest publically‐funded health coverage program.

Introduction In the post‐health reform flurry of speculation and amidst the scramble to prepare for 2014, the

Accountable Care Organization (ACO)—which is the focus of the newly created Innovation Center within

the Center for Medicaid and Medicare Services (CMS)—is emerging as a centerpiece of federal strategy

to implement vast coverage expansions while also assuring and promoting quality of care, improving the

health status of defined populations and, at the same time, not bankrupting future generations. It

appears that CMS is seriously and quickly moving to assist in the establishment of these new delivery

systems.

Further, the focus on integrated health care delivery is being echoed in the renewal of the California

Medicaid Waiver,1 which will precede national reform in its implementation. Both major Waiver

Health Management Associates November 2010

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components—expansion of the “Coverage Initiative” for the uninsured and the transition of Seniors and

Persons with Disabilities (SPDs) from fee‐for‐service into managed care—will require a new integrated

delivery approach that is reflective of the basic tenets of an ACO model. The Waiver offers a further

incentive to California providers that rely on Medicaid reimbursement to start moving toward new

accountable care models that will ultimately be required under federal reform.

Why should the Safety Net focus on the development of integrated delivery systems, including ACOs?

The ACO concept is still indistinct. Past CMS demonstrations have involved large physician groups with

predominantly Medicare and commercially insured patients—not the primary populations served by the

Safety Net. The vision of shared responsibility required by an ACO is complicated within the Safety Net

which includes entities as disparate as public health and hospital systems, Federally Qualified Health

Centers (FQHCs), private community hospitals and physician groups. State Medicaid agencies will need

to be involved in ACOs focused on the Safety Net and they are now inundated with budget deficits and

faced with staff furloughs. It may seem more prudent, and certainly easier, to wait and see how things

fall out as health reform moves toward implementation.

However, there is a compelling case to be made that the Safety Net should not only participate in the

development of ACOs and other integrated delivery system models, they should lead. Among the

reasons to proceed aggressively now are the following:

CMS needs models for ACOs that target the populations cared for by the Safety Net. Patients

covered by Medicaid and the uninsured will be a significant focus for health reform expansion in

2014. Safety Net systems have the opportunity to help shape the evolving concept of ACOs for

these groups. Safety Net systems can build collaborations with little active competition from

others concentrating on ACOs predominately serving Medicare and commercial patients.

The Safety Net would benefit from the support that will be offered by CMS to prepare for the

massive change that this transformation will require. An ACO governance model will need to

be built that takes into account the various accountabilities of County systems, FQHCs and

private hospitals and physicians. An ACO finance strategy will need to be conceived that

transforms the current complexity of Intergovernmental Transfer agreements (IGTs),

Disproportionate Share Hospital (DSH) payments and FQHC PPS reimbursement into a

“bundled” revenue stream that encourages efficiencies and best practices. Clinical silos will

need to be replaced with integrated approaches and shared agreement on approaches to care

delivery. This transformation will require an infusion of financial, regulatory, legal and technical

assistance.

Local community and government support of health care in California is currently an

advantage but may change under health reform and new delivery systems will need to be

developed that assure access and maximize efficient use of resources. In California, counties

have long been mandated to address the care of the medically indigent and, while this charge

has materialized in different forms, the building blocks are there to begin to construct a new

model. Further, as health reform moves toward implementation, the role of local government as


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both a payor and provider of health care services will, more and more, come into question. This

next period of time, with potential for both State and federal support, provides a window of

opportunity for the local Safety Net to define and shape its role in the future.

The core principles inherent in ACOs offer a strategy to the Safety Net to improve health

outcomes and reduce costs. The care provided in the Safety Net should be more coordinated,

produce better outcomes, result in greater patient satisfaction and cost less. This is an

opportunity for providers to be supported to do what they know should be done anyway.

This paper offers a broad analysis of the elements of ACOs and their likely role in the future, the

particular challenges faced by the Safety Net in moving toward this new model and basic steps that

Safety Net providers need to take to achieve a population‐focused, collaborative approach to delivering

health care services. While the focus of this paper is on the ACO (because of the emerging federal

opportunities), the principles that make up these models are applicable to many different approaches to

integrated care delivery that would be of significant benefit to the Safety Net. It is the premise of the

authors that the Safety Net must be preserved—not because “it is too big to fail” but because it is likely

to continue to be needed2 and has a responsibility to survive. The lessons of the past have confirmed

that “coverage” does not equal “access.” There will always be those that have no other place to go for

care and there will always be those that rely on the services that only Safety Net providers have the

experience and expertise to provide. The potential failure of Safety Net providers would have a more

profound impact than the failure of other providers for whole communities and for their most

vulnerable residents.

It will be important, though, not to be like the generals who

repeatedly plan to “win the last war;” preparation must be for the

emerging challenges ahead. The transition period between the way

that care is delivered and funded today to the model for the future

will be the most critical time for the Safety Net. Lack of capital and

infrastructure, difficult and cumbersome bureaucracies and

governing organizations, financial arrangements that reward

processes and expenditures rather than quality and outcomes—all

of these issues are very real in the Safety Net and will take

leadership, collaboration and intensive effort to address. It must be

done, however, and it must start now.

What is “Accountable Care”? “Accountable care” is a mechanism that the federal government hopes will address what is widely

acknowledged to be poor value for the money spent in the U.S. health system, which is more expensive

and inflationary while, at the same time, failing to achieve even comparable health status of other

countries.3 Further, within the borders of the United States, there is wide variability of health care costs

and no seeming relation between the cost of care and the outcomes achieved.4 Health care in this

country can be dazzling and dramatic but fails to broadly provide even half of the services

It will be important (for the Safety Net) not to be like the generals who repeatedly plan to “win the last war;” preparation must be for the emerging challenges ahead.


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recommended to achieve and maintain good health, resulting in life spans, infant mortality rates,

potential years of life lost, and health‐related quality of life that are clearly subpar. In addition, the

population is generally dissatisfied with their care and certain populations have shamefully and

disproportionately poor health outcomes.

If health care value were improved, it would mean the population would receive more value for what

they pay. This could happen if health care quality and outcomes improved while cost remained the same

or if costs decreased while quality remained constant. Of course, improving quality and decreasing cost

would enhance value the most. Expanding health insurance coverage for the population is necessary but

not sufficient to improve value. Coverage might improve outcomes for those who previously had no

access to medical care but would also add new cost and would not end the current inflationary spiral.

Further, increased coverage might not completely address access problems as providers shift their focus

to take advantage of the most profitable “lines of business,” while avoiding “losing services,” leaving

already underserved communities with high risk populations served unequally. This complex

intersection of cost, quality and health status is the paradigm that ACOs are meant to address.

While the definition of ACOs is still being fully refined and may, in fact, take multiple forms, several

elements must be in place. Care must be provided to a distinct population, large enough to be able to

show a clear impact of organized care delivery but not too large that such an impact would be

impossible to accomplish. The ACO should eventually care for patients covered by all types of payers,

public and private. The ACO must be driven by providers, with decisions made that reflect the elements

of practice that can deliver higher quality care at lower cost. Among current providers, there are likely to

be winners and losers in a successful ACO. Based on previous federal ACO demonstration experience, it

is clear that, to achieve its objectives, a new practice model must be adopted that is heavily focused on

primary care medical homes, care management and connective health information technology.5

Progress in meeting cost, quality and improved health status goals must be able to be measured. A new

financial model must be established that aligns provider incentives to meet cost, quality and health

status improvement objectives rather than basing payment on service volume. Finally, ACO governance

must rely on integrated clinical leadership, organized in a way to constantly evaluate medical evidence

and health outcomes and, as necessary, alter resources and practice to meet the needs of the

population.

What are Challenges for Safety Net Participation in Accountable Care? The Safety Net has been determined to be “those providers that organize and deliver a significant level

of health care and other health‐related services to uninsured, Medicaid, and other vulnerable

patients.6”These providers typically include public health care systems, FQHCs, community hospitals that

serve vulnerable populations (because of either mission or geography), and private practitioners located

in underserved areas. Health care delivered by the Safety Net is financed predominantly by Medicaid,

local government funds, out‐of‐pocket payments by patients, Medicare, and a small percentage of

commercial health insurance.7 A significant, but undetermined amount of care is completely

uncompensated. Patients served by the Safety Net have generally lower health status than that of the

broader population in their communities, whether measured by health outcomes or self‐reported, and

TITLE:

OUR COMMUNITIES, OUR ISSUES, OUR COUNTRY

ISSUES AND RECOMMENDATIONS FROM THE NATIONAL COALITION OF ASIAN PACIFIC AMERICANS (NCAPA)

NATIONAL COALITION OF ASIAN PACIFIC AMERICANS (NCAPA)

THE NATIONAL COUNCIL OF ASIAN PACIFIC AMERICANS (NCAPA), FOUNDED IN 1996, IS A COALITION OF THIRTY-ONE ASIAN PACIFIC AMERICAN ORGANIZATIONS AROUND THE

COUNTRY. BASED IN WASHINGTON D.C, NCAPA SERVES TO REPRESENT THE INTERESTS OF THE GREATER ASIAN AMERICAN (AA) AND NATIVE HAWAIIAN PACIFIC ISLANDER (NHPI)

COMMUNITIES AND TO PROVIDE A NATIONAL VOICE FOR AA AND NHPI ISSUES.

ASIAN & PACIFIC ISLANDER AMERICAN HEALTH FORUM ASIAN & PACIFIC ISLANDER AMERICAN SCHOLARSHIP FUND

ASIAN & PACIFIC ISLANDER AMERICAN VOTE ASIAN AMERICAN JUSTICE CENTER

ASIAN PACIFIC AMERICAN INSTITUTE FOR CONGRESSIONAL STUDIES ASIAN PACIFIC AMERICAN LABOR ALLIANCE

ASIAN PACIFIC PARTNERS FOR EMPOWERMENT, ADVOCACY, & LEADERSHIP ASSOCIATION OF ASIAN PACIFIC COMMUNITY HEALTH ORGANIZATIONS

BPSOS COUNCIL FOR NATIVE HAWAIIAN ADVANCEMENT

HMONG NATIONAL DEVELOPMENT JAPANESE AMERICAN CITIZENS LEAGUE LAOTIAN AMERICAN NATIONAL ALLIANCE

LEADERSHIP EDUCATION ON ASIAN PACIFIC’S, INC. NATIONAL ALLIANCE OF VIETNAMESE AMERICAN SERVICE AGENCIES

NATIONAL ASIAN AMERICAN PACIFIC ISLANDER MENTAL HEALTH ASSOCIATION NATIONAL ASIAN PACIFIC AMERICAN BAR ASSOCIATION NATIONAL ASIAN PACIFIC AMERICAN FAMILIES AGAINST SUBSTANCE ABUSE

NATIONAL ASIAN PACIFIC AMERICAN WOMEN’S FORUM NATIONAL ASIAN PACIFIC CENTER ON AGING

NATIONAL ASSOCIATION OF ASIAN AMERICAN PROFESSIONALS NATIONAL COUNCIL OF ASIAN PACIFIC ISLANDER PHYSICIANS

NATIONAL COALITION FOR ASIAN PACIFIC AMERICAN COMMUNITY DEVELOPMENT NATIONAL FEDERATION OF FILIPINO AMERICAN ASSOCIATIONS NATIONAL JAPANESE AMERICAN MEMORIAL FOUNDATION

NATIONAL KOREAN AMERICAN SERVICE & EDUCATION CONSORTIUM NATIONAL QUEER ASIAN PACIFIC ISLANDER ALLIANCE

OCA SIKH AMERICAN LEGAL DEFENSE AND EDUCATION FUND

SOUTH ASIAN AMERICANS LEADING TOGETHER SOUTHEAST ASIA RESOURCE ACTION CENTER

ABOUT OUR COMMUNITIES

• With a population of 18.5 million, Asian Americans, Native Hawaiians, and Pacific Islanders (AA & NHPIs) represent 5.6 percent of the total U.S. population according to the 2010 Census.

• Between 2000 and 2010, the Asian American population grew by 43% and the NHPI population grew by 30%.

• AA and NHPIs come from over 30 countries and speak over 100 languages, and contribute to every sector of American life.

ABOUT THE ISSUES

We present six issues with key recommendations for policymakers, stakeholders, and community leaders, which are even more relevant during the 2012 election season. These issues are Civil Rights, Education, Health, Housing and Economic Justice, Immigration, and Native Hawaiian and Pacific Islanders. The recommendations presented below serve as a point of entry for greater discussion, dialogue, and analysis at the local and national levels.

• CIVIL RIGHTS Our community members often face bias and discrimination in the workplace, at the polls, in their neighborhoods, in schools, and within the political process. Not only do AA & NHPI community members endure such treatment based on the perception of being “perpetual foreigners”, but individuals are often also targeted for their actual or perceived national origin, religion, gender, sexual orientation, and economic status. Key Recommendations:

• Voting Rights: Support the continuing vitality of the Voting Rights Act, including full enforcement of Section 203 (requiring language assistance in the elections process in specific jurisdictions); and ensure access to the voting process for all U.S. citizens by opposing voter suppression efforts, such as voter photo identification requirements

• Racial and Religious Profiling: Support legislation, such as the End Racial Profiling Act, prohibiting racial and religious profiling by federal, state, and local law enforcement; strengthen the existing Department of Justice guidance on racial profiling; and oppose measures allowing indefinite detention of individuals without charge

• Discrimination and Bias-based Bullying: Support enforcement of existing anti-‐discrimination policies for AA & NHPI communities and passage of legislation, such as the Employment Non-Discrimination Act and the Workplace Religious Freedom Act, expanding anti-‐discrimination policies; support legislation, such as the School Safety Improvement Act, encouraging educators to adopt measures to combat bullying and establishing grievance procedures for students and families

EDUCATION

Asian Americans, Native Hawaiians and Pacific Islanders (AA & NHPIs) are far too often stereotyped by the so-‐called “model minority myth,” which is rooted in the misconception that all AA & NHPIs are exceptional students, and face no barriers while on the path to higher education. However, educational disparities are vast within segments of our communities. For example, the American Community Survey 2008 indicates that while more than a majority of the Asian Indian community have a bachelor’s degree or above (68%) and only 10% have only a high school degree, less than 15% of the Cambodian community has a bachelor’s degree or above and about a quarter have only a high school degree (24%).

Key Recommendations:

• Ensure that schools have the capacity to serve AA & NHPI students by including high quality data, increased resources for ELL students, and protections for safe schools in reauthorization of the Elementary and Secondary Education Act (ESEA).

• Support educators and staff by providing high quality and research-‐based professional development to work with diverse AA & NHPI students, particularly AA & NHPI ELL students and limited English proficient families.

• Provide adequate funding and technical assistance to Asian American Native American Pacific Islander Serving Institutions qualified institutions of higher education.

Health

Asian Americans, Native Hawaiians and Pacific Islanders (AAs and NHPIs) are disproportionately represented among the uninsured, and many of our low-‐income families must rely on publicly supported health care programs for their health care needs. Currently, more than 2.3 million Asian Americans and 162,000 Native Hawaiians and Pacific Islanders are uninsured. Moreover, our community members face health disparities and unequal access to quality health care services that especially impact those who are low-‐income, limited English proficient, and new residents.


• Promote access to quality, affordable, and culturally and linguistically competent health care, including comprehensive reproductive, mental and behavioral health care, for AAs and NHPIs by supporting the full funding and implementation of the Affordable Care Act.

• Reduce health disparities and expand access to preventive services and treatment of chronic diseases such as hepatitis B, diabetes, cancer, mental health, and substance use disorders.

• Advocate for the collection, reporting and analysis of standardized, disaggregated demographic and health data on AA and NHPIs in order to reduce health and health care disparities and eliminate barriers to quality health services.

Housing and Economic Justice

In light of the foreclosure access and slow pace of economic recovery, AAPI community members like all Americans are facing challenging situations – from job loss to declining wealth and assets in communities and lack of financial security. The foreclosure crisis has wreaked havoc on neighborhoods throughout the country, threatening access to affordable and stable housing choices for many AA & NHPIs. With the subsequent recession and slow pace of the economic recovery leading to significant job losses and declining wealth and assets in our communities, many AA & NHPIs have been stripped of their financial security and means for upward mobility. These economic hardships continue to severely impact the most vulnerable in our communities and only exacerbate our nation’s wealth disparities and racial economic inequalities.


• Support housing and neighborhood revitalization programs that increase the supply of affordable housing, promote housing stability, preserve access to affordable homeownership opportunities, and revitalize neighborhoods for low-‐income and low-‐wealth communities.

• Support asset building and financial security programs that assist individuals and families to make informed financial decisions, increase savings and develop assets, improve access to credit, and provide strong consumer protections in the financial marketplace.

• Support workforce investment and economic development programs that create jobs, provide job training opportunities, enhance protections in the workplace and ensure the stability and revitalization of our neighborhoods.

Immigration

Nearly two-‐thirds of Asian Americans are foreign born and approximately 1 million of the 10.8 million undocumented people in the country are of Asian origin. Despite the contributions of Asian immigrants to all sectors in our country, community members have experienced a long and deep history of racist and restrictive immigration laws. Today, the broken immigration system makes it difficult for Asian Americans to immigrate to the U.S. and to fully contribute to this country. Key Recommendations:

• Support comprehensive immigration reform at the federal level that (1) Creates a broad and simple process that provides a path to citizenship for undocumented immigrants; (2) Keeps American families together, including same-‐sex households; (3) Improves and strengthens avenues and protections for immigrant workers and their families to live and work in the country; (4) Ensures the due process rights of all in the United States and prioritizes human rights standards through reforms in the detention and deportation systems; and (5) Supports the full integration of immigrants.

• Reject enforcement-‐only approaches to immigration, including anti-‐immigrant proposals and initiatives at state and local levels.

• Support pro-‐immigrant measures at federal, state and local levels, including in-‐state tuition bills.

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