duval county health department operational assessment site visit report june 2012

7/30/2019 Duval County Health Department Operational Assessment Site Visit Report June 2012

1/38

This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care

(HRSA/BPHC) to assist in providing guidance and oversight of the HRSA/BPHC grantee. Information provided in this report is restricted to

HRSA/BPHC use and cannot be distributed, copied, shared, and/or transmitted without written permission from HRSA/BPHC and the Review Team.

BUREAU OF PRIMARY HEALTH CARE SITE VISIT REPORT

Consolidated Team Report

1 of 38

The purpose of the site visit is to provide direct support to grantees on key health center programrequirement(s) and to identify any areas(s) for potential performance or operationalimprovements. Attached are the preliminary findings and recommendations from the site visitteam that have been identified by the consultants as a result of the site visit process. This report

is not exhaustive, but identifies any key program requirement findings/recommendations(s) aswell as any recommended area(s) for performance or operational improvement.

Task Order #: CSED-12-0060

Part One

Grantee Information: Duval County Health Department1760 Edgewood Avenue WestJacksonville, Florida 32208

Contact: Renee [email protected]

Type of Visit: Operational Site Visit

Purpose of Visit: In addition to reviewing the grantees compliance with and performance inthe 19 key health center program requirements, another purpose for this site visit is to examinethe co-applicant relationship between the health center and the county health department.

Dates of Visit: June 25 - 27, 2012

Consultants: Kathleen Wolf, M.P.A. (fiscal)

Gary Cooper, M.D. (clinical)

Vincent Lee, O.D., M.B.A. (administrative/governance

and team leader)

Overview of Grantee Organization: The grantee is the Duval County Health Department(DCHD), which is part of the public health effort of the Florida Department of Health, whichaccording to the FDOH website has 67 such county health departments throughout the state.DCHD, through a co-applicant agreement, operates the Agape Community Health Center

(ACHC), which does business as Agape Community Health Network (ACHN), with five sites(six if the co-located pharmacy at 1760 Edgewood Avenue West is included) providing servicesacross the Jacksonville metropolitan area. Two clinicsthe Agape Community Health Centerand the Wesconnett Family Health Centeroffer adult medicine, pediatrics and womens health.Adult medicine and pediatric services are also provided at the West Jacksonville location. TheSouth Jacksonville Family Health Center offers pediatrics, while the South Jacksonville PrimaryHealth clinic offers adult medicine. Primary medical care, including screenings for cancer,cholesterol, lead, vision; diagnosis and treatment of communicable diseases; immunizations;


2/38






2 of 38

family planning; well child care; and urgent care are provided at ACHC. Specialty servicessuch as ENT, dermatology, orthopedics and surgery are provided by referral to the ShandsJacksonville Medical Center.

Laboratory services are provided by LabCorp, Quest Diagnostics and the State Laboratory.Patients are referred to the Shands Jacksonville Medical Center for radiology services.Behavioral healthservices including substance abuse counseling and treatment are provided byseveral referral agencies including River Region Behavioral Health and CommunityRehabilitation Center.

As mentioned, pharmacy services are provided on site by DCHD/ACHC Pharmacy located at theEdgewood Street address. The pharmacy participates in the 340B Drug Pricing Program, as wellas prescription assistance programs. Patients also access pharmacy services from localpharmacies in their neighborhoods.

As part of the FDOH, the principal systems, e.g., accounting, budgeting, cash management,accounts receivable, payroll, human resources, information technology, are operated by the State.These systems provide economies of scale. That is, there are cost advantages and operationalefficiencies realized by the volume of transactions or data, expertise of assigned personnel,updated technology, etc., and the FQHC is able to draw on the resources of the organization.This access to resources and the organizations diversification of resources tends to insulate theFQHC from cash flow problems, unanticipated expenses, or economic downturns.

The Bureau of Primary Health Care awarded $1,503,090 to the FQHC for the fiscal year endingDecember 31, 2012. Patient fees and third party billing account for $5.9 million. The FQHCstotal annual budget is $7.5 million. The health center has underspent its federal grant in the past,mostly due to vacant positions.

The ACHC board is composed of ten members, only seven of whom have attended board meetingswith any regularity in the last two years, a situation that has made it very difficult to generate aquorum even for meetings that are held by conference call. The four officers of the corporation,who have all served on the governing body since 2004, demonstrate a high level of dedication andengagement as board members, and bring leadership and a level of expertise in different areas thatare valuable to the community health center. However, the board is not adhering to the corporateby-laws as they relate to removing inactive and non-participating members, and it needs to recruitsuitable replacements. It also needs to re-establish its position in the partnership with the DCHD,which has become out of balance. The original co-applicant agreement is not especially detailed,and should be reviewed and updated by both parties, after long-overdue and much-neededdiscussions and negotiations that should clarify the responsibilities and boundaries between theHealth Department and the board of directors for the health center and re-establish their respectiveroles in this partnership.


3/38






3 of 38

Site Visit Participants:

Name & Title of Participant Interviewed Entrance Exit

Renee Pollard, E.D., ACHC Y Y Y

Kenneth Nixon, M.D., CMO, ACHC Y Y YAngela Hicks, Chief Nursing Officer,

Duval County Health Department Y Y N

Leigh Wallace, D.D.S., dentist on

mobile dental unit (via phone) Y N N

Tim Lawther, Assistant Director &

Interim CFO, Duval County Health Dept. Y Y Y

Victor Ferreira, Director of Clinical

Operations, Duval County Health Dept. N Y Y

Robert Harmon, M.D., Director,Duval County Health Dept. Y N Y

Catherine Butterfield, Office Manager,

South Jacksonville clinic, ACHC Y N N

Judith Wilson, Interim Nurse Supervisor,

South Jacksonville clinic, ACHC Y N N

John Mosley, B.S.B.A.,

Clinical Practice Administrator and

Quality Improvement Coordinator Y N N

Sunila Philipose, R.Ph., Pharmacist Y N NEileen Snyder, Credentialing

Coordinator Y N N

Landon Williams, Chair, BOD Y N N

Deborah Thompson, Co-Chair, BOD Y N N

Noel Lawrence, Treasurer, BOD Y N N

Solomon Badger, Secretary, BOD Y N N

List of Documents Reviewed:

Fiscal:

DOH County Health Department Sliding Fee Scale, Effective February 1, 2012

DOH County Health Department Program Eligibility Annual Income Guidelines, EffectiveMarch 3, 2011

DCHD/FQHC Self Financial Evaluation Form

Health Management System (HMS) System Description


4/38






4 of 38

Duval County Health Department Financial Eligibility Determination Policies and Procedures,Revised 1/9/12

County Health Department Accounts Receivable Policies, DOHP 56-66-08

Board of Directors Meeting Minutes September 2011 through October 2011

DCHD Administration Health Services Business Operations Manual

Wesconnett Community Health Center Support Agreement

Mobile Unit Community Support Agreement

Memorandum of Agreement between Community Rehabilitation Center, Inc. & AgapeCommunity Health Network / Duval County Health Department

Memorandum of Agreement between MuslimCare, Inc. and the Florida Department of HealthDuval County Health Department

Contract between City of Jacksonville and State of Florida Department of Health for theOperation of the Duval County Health Department

MOA between State of Florida Department of Health Duval County Health Department andJacksonville Job Corp Center

MOA between River Region and Agape Community Health Center

MOA between Gateway Community Services and Agape Community Health Center

Agreement between University of Florida and Duval County Health Department for LaborDelivery Services

Agreement between State of Florida Department of Health Duval County Health Department andAgape Community Health Center (Governing Board)

Delineation of Shared Co-Applicant Responsibilities for Agape community Health Network

Agreement between Agape Community Health Center Inc. and Shands Jacksonville Medical

Center, Inc.Payroll Registers 5/11/12 - 5/24/12 and 5/25/126/7/12

Lease Agreement with St. Vincents Ambulatory Care, Inc. 4/1/03 through 3/13/12

State of Florida Department of Health Standard Contract with University of Florida Boardof Trustees

State of Florida Department of Health Standard Contract with Florida A and M University

Florida Department of Health Duval County Health Department Request for Proposal forJanitorial Services

Project Narrative HRSA Grant H80CS00851 Attachment 1

FQHC Budget Variance Report

NGA Grant Award 6 H80CS00851 09-02 for budget period ending December 31, 2012

Florida Medicaid letter, dated May 24, 2012, regarding eligibility for associated payment

Notice of Medicaid Reimbursement Rate Change Form for CHDs, dated 7/26/11

Statement of Financial Position May 31, 2012

Statement of Activities YTD, May 31, 2012

Encounters by Site May 2011 through May 2012


5/38






5 of 38

Annual Patients by Service Lines

Performance Progress Report SF-PFR FY2012

Form 3 Income Analysis

UDS Health Center Trend Report, 2009, 2010, and 2011

Department of Health Finance and Accounting FLAIR Budgetary Transaction DOHP 56-20-11

State of Florida Auditor General Summary Report of Compliance and Internal Controls overFinancial Reporting and Federal Awards 7/1/096/30/11

Agape Community Health Network Strategic Plan 20092013

Clinical:

UDS Health Center Trend Report 2010

UDS 2011

Quality Assurance/Quality Improvement Plan

Provider Meeting minutesClinical Policies and Procedures

Risk Management Plan

Risk Management Committee Meeting minutes

CLIA license

Credentialing and Privileging Policy and Procedure

Provider files

Administrative/Governance:

By-lawsBinder containing slides from board trainings

Duval County Health Need Profile

Strategic Plan 2009 - 2013

Organizational chart

Board member membership lists with area of expertise, ethnicity, start date on BOD

March 2010March 2012 board meeting minutes

Clinic services reports for BOD members

1/1/112/29/12 Performance Evaluation for Renee Pollard (not signed by Ms. Pollard or

Tim Lawther)Delineation of Shared Co-Applicant Responsibilities for Agape Community Health Network

[Co-Applicant] Agreement Between the State of Florida, Department of Health, Duval CountyHealth Department and Agape Community Health Center (Governing Board)

Lease for 1760 Edgewood Avenue West, Jacksonville, FL (main site, 10,324 square ft.)

Contract between Florida Department of Health and the University of Florida to providephysicians to FDOH


6/38






6 of 38

Contract between Florida Department of Health and the Florida A&M University to manage theDCHD pharmacy program

Agreement between Duval County Health Department and St. Vincents Ambulatory Care, Inc.,to provide hospital funding for clinic staff at the Wesconnett CHC site to help reduce

unnecessary ER visitsAgreement between Duval County Health Department and St. Vincents Ambulatory Care, Inc.,

to provide hospital funding for the mobile unit

Memorandum of Agreement between Duval County Health Department and CommunityRehabilitation Center, Inc., to provide physical exams and follow-up care to health centerclients

Memorandum of Agreement between Duval County Health Department and MuslimCare, Inc.,to provide access to medical care for clients of MuslimCare

Contract between the Florida Department of Health and Duval County Health Department forprovision of patient services and FDOH funding

Memorandum of Understanding between Duval County Health Department and Jacksonville JobCorps Center to provide practicum experience to JJCC students

Memorandum of Understanding between Agape CHC and River Region to accept each othersreferrals for substance abuse and mental health services and primary care services,respectively.

Memorandum of Understanding between Agape CHC and Gateway Community Services toaccept each others referrals for substance abuse and mental health services and primarycare services, respectively.

Agreement between Duval County Health Department and the Department of Obstetrics andGynecology, College of Medicine-Jacksonville, University of Florida for labor anddelivery services.

List of Documents Left With Grantee:

HRSA Policy Information Notice 2002-22 (Clarification of Credentialing and Privileging Policy)

Primary Compliance Issues, Concerns, and/or Performance Improvement Opportunities

Addressed During Visit:

Fiscal:

The relationship between DCHD and the FQHC entails the need for collaborations among all thekey stakeholders. Strong lines of communication are necessary in order to minimize the negativeeffects of fragmentation. Many of the deficiencies noted in the operational assessment stemfrom fragmentation of responsibilities and poor communication. These deficiencies will beresolved only by systemic solutions, not merely by re-assigning personnel or improving writtendocumentation.


7/38






7 of 38

Although revenue and expenditures in the current grant period do not vary significantly from thebudget, the FQHCs past record of underspending is a particular concern. The budget reflectsthe planned Scope of the Program for the grant year and includes both grant funds and programincome. If all proposed services are offered, the FQHC will not experience surplus funds.

Under spending often indicates a failure to accomplish the program plan. The fragmentation ofresponsibilities and poor communication impedes the FQHC from preparing budget forecastsand implementing timely budget strategies.

Clinical:

Contracts/agreements with local hospitals.


Compliance Issues:

There is no recent needs assessment.

Monthly board meetings are not held, and those that have been held seldom have a quorum of atleast six members.

The board must start immediately to identify and recruit appropriately qualified candidates to beconsidered for board membership.

There are no statements signed by the board members attesting to their not having any conflictsof interest.

Performance Improvement Opportunities:

There should be an up-to-date written agreement between ACHC and the Duval County HD that

clearly states what infrastructure is being provided to the health center.The organization chart should be corrected immediately.

There should be a clear indication in the board meeting minutes binder whenever a monthlyboard meeting is not held.

The ACHC board should enforce the by-law that requires the removal of board memberswho have three unexcused absences.

There are several key areas of expertise that should be represented on the board.

Specific Actions Taken During Site Visit:

Fiscal:

Tour of Agape Community Health Center and South Jacksonville Primary Health Center.

Interviewed the Director and Assistant Director of DCHD.

Provided fiscal technical assistance on budget strategies.


8/38






8 of 38

Clinical:

Tour of Agape Community Health Center and South Jacksonville Primary Health Center.

Provided Quality Improvement technical assistance to the Medical Director and QI Coordinator.


Conducted the entrance conference with the Executive Director of ACHC and DCHD managersin attendance.

Interviewed the Director and Assistant Director of DCHD.

Toured the main and South Jacksonville sites.

Conducted a lunch meeting with members of the ACHC board of directors.

Led the exit conference with the Executive Director of ACHC and DCHD managers

in attendance.

Innovation/Best Practices: The Hospital Emergency Room Alternative Program (HERAP) hasdecreased ER visits, hospital admissions, and days in hospital, as well as improved HbA1c inuninsured patients utilizing disease management, case management, and self-managementeducation. Clinical pharmacists assist with medication dosage, drug interactions, one on onepatient education and prescription assistance programs.


9/38






9 of 38

Part Two

SECTION 1: Need

Program RequirementsProgram Requirement # 1 - Needs Assessment: Health center demonstrates and documents theneeds of its target population, updating its service area, when appropriate (Section 330(k)(2) andSection 330(k)(3)(J) of the PHS Act).

Findings/Factors: Not Met.

There is no recent needs assessment; in fact, the Executive Director has not been able to obtaina copy of the last needs assessment from the Florida Department of Health despite multiplerequests. (This may or may not be related to issues the Executive Director has with opening

electronic documents.) The consultant reviewed a County Health Need profile for Duval Countythat makes an initial assessment of the need for medical, dental and behavioral health servicesby census tract by assigning numerical values that are determined by objective performancemeasures in different areas. (For example, population to provider ratios, percentage ofpopulation that is uninsured, percentage of adults without a dental encounter in the past year,and/or psychiatric hospitalization rates.) However, this profile does not draw any conclusions,set any priorities, or make any recommendations.

Recommendations: The grantee is required to demonstrate and document the primary healthcare needs of its target population and to update its service area when appropriate. A new needsassessment must be conducted that results in an analysis that thoroughly describes the service

area, service area overlaps, and target population(s) and identifies available resources, anybarriers to care, any gaps in service and the external factors affecting these conditions. Thisinformation should be part of an exhaustive set of data that can then be utilized in the granteesstrategic planning process, which itself should yield a new three- to five-year blueprint (the latestone is only through 2013) that the senior management and board of directors can utilize to guidetheir efforts to meet the primary health care needs of its target populations in the most cost-effective and efficient manner. It is strongly recommended that the Executive Director and theboard of directors seek the assistance they need to develop a strategic planning process and tostart that process by December 1, 2012, to allow the health center to enter its next fiscal yearwith a set of very specific objectives distilled from the new strategic plan that can be reflected inits annual business plan and budgets.


10/38






10 of 38

SECTION 2: ServicesProgram Requirements

Program Requirement #2 - Required and Additional Services: Health center provides all

required primary, preventive, enabling health services and additional health services asappropriate and necessary, either directly or through established written arrangements andreferrals (Section 330(a) of the PHS Act).

Note: Health centers requesting funding to serve homeless individuals and their families mustprovide substance abuse services among their required services (Section 330(h)(2) of the PHSAct).

Findings/Factors: Met.

Under the auspices of the Duval County Health Department (DCHD), Agape Community HealthCenter (ACHC) provides adult medicine, pediatrics and womens health (which includesgynecology, family planning, and prenatal care) at five locations across the Jacksonvillemetropolitan area. Two clinicsthe Agape Community Health Center and the WesconnettFamily Health Centeroffer adult medicine, pediatrics and womens health. Adult medicineand pediatric services are also provided at the West Jacksonville location. The SouthJacksonville Family Health Center offers pediatrics, while the South Jacksonville Primary Healthclinic offers adult medicine and womens health.

Primary medical care including screenings for cancer, cholesterol, lead, vision; diagnosis andtreatment of communicable diseases; immunizations; family planning; well child care; andurgent care are provided at ACHC. Specialty services such as ENT, dermatology, orthopedicsand surgery are provided by referral to the Shands Jacksonville Medical Center.

Laboratory services are provided by LabCorp, Quest Diagnostics, and the State Laboratory.Patients are referred to the Shands Jacksonville Medical Center for radiology services.Behavioral healthservices including substance abuse counseling and treatment are provided byseveral referral agencies including River Region Behavioral Health, and CommunityRehabilitation Center.

Pharmacy services are provided on-site by DCHD/ACHC Pharmacy located at the EdgewoodStreet address. The pharmacy participates in the 340B Drug Pricing Program, as well asprescription assistance programs. Patients also access pharmacy services from local pharmaciesin their neighborhoods.

Recommendations: Performance improvement is urged.


11/38






11 of 38

Areas for Performance Improvement

Performance Improvement Area: Pharmacy Services

Findings/Factors: Pharmacy services are offered at only one of five DCHD/ACHC locations.

Recommendations: Consider the feasibility of expanding pharmacy services to other cliniclocations.

Program RequirementsProgram Requirement #3 - Staffing Requirement: Health center maintains a core staff asnecessary to carry out all required primary, preventive, enabling health services and additionalhealth services as appropriate and necessary, either directly or through established arrangementsand referrals. Staff must be appropriately credentialed and licensed (Section 330(a)(1) and (b)(1),

(2) of the PHS Act).


Agape Community Health Center utilizes a team model at each clinic, consisting of a clinicalprovider (physician or nurse practitioner) with a nurse, health support technician (HST) andclerk. There is dedicated staff assigned to each of the clinics. Staffing is sufficient to provideprimary, preventive, and enabling health services.

Recommendations: Performance improvement is indicated.


Performance Improvement Area: Credentialing and privileging.

Findings/Factors: In the DCHD Clinical Privileges Policy under Section V (Definitions), thedefinitions for credentialing and privileging are described. However, throughout the policy, theemphasis is on privileging; no statement in the policy addresses credentialing of providers.Although the credentialing process is described in Section VIII.B, this process is referred to asthe privileging process.

Recommendations: The Clinical Privileges Policy needs to bere-written to reflect credentialing

as a separate and distinct function from privileging. According tothe HRSA Policy InformationNotice (PIN) 2001-16, Credentialingis the process of assessing and confirming thequalifications of a licensed or certified health care practitioner. Privileging is the process thathealth care organizations employ to authorize practitioners to provide specific services to theirpatients.


12/38






12 of 38

Program RequirementsProgram Requirement #4 - Accessible Hours of Operation/Locations: Health center providesservices at times and locations that assure accessibility and meet the needs of the population to

be served (Section 330(k)(3)(A) of the PHS Act).


The Agape Community Health Center hours of operation are: Monday 8:00 AM to 7:30 PM, andTuesday through Friday 8:00 AM to 5:00 PM.

The hours of operation at the West Jacksonville Family Health Center are: Monday 8:00 AM to5:00 PM, Tuesday 8:00 AM to 7:30 PM, and Wednesday through Friday 8:00 AM to 5:00 PM.

The South Jacksonville Family Health Center location is open Monday through Friday 8:00 AM

to 5:00 PM.

The South Jacksonville Primary Care Centers hours of operation are: Monday 8:00 AM to 5:00PM, Tuesday 8:00 AM to 7:30 PM, and Wednesday through Friday 8:00 AM to 5:00 PM.

The hours of operation for the Wesconnett Family Medical Center are: Monday 8:00 AM to 7:30PM, Tuesday through Friday 8:00 AM to 5:00 PM and Saturday 8:30 AM to 3:00 PM.

The locations of the clinical sites are in areas of need and cover all quadrants of the city.All sites are accessible by public transportation.

A mobile medical van is scheduled to begin operation in July 2012 to provide services toneighborhoods and schools in several areas of Jacksonville.

Recommendations: Performance improvement is recommended.


Performance Improvement Area: Evening Hours

Findings/Factors: Evening hours are held at Agape and Wesconnett on Mondays and at WestJacksonville and South Jacksonville Primary Care on Tuesday evenings. There are no evening

hours on Wednesday or Thursdays at any clinic location.

Recommendations: To improve the availability of medical services, considerrotatingeveninghours among all clinic locations to include Wednesday and Thursday evenings.


13/38






13 of 38

Program RequirementsProgram Requirement #5 - After-Hours Coverage: Health center provides professionalcoverage during hours when the center is closed (Section 330(k)(3)(A) of the PHS Act).


After-hours coverage is provided by an on-call physician or nurse practitioner. Patients call theanswering service, which in turn contacts the on-call physician/nurse practitioner. Evenings andweekends are covered by a rotating schedule of providers.

Recommendations: None.

Program RequirementsProgram Requirement #6 - Hospital Admitting Privileges and Continuum of Care: Health center physicians have admitting privileges at one or more referral hospitals, or othersuch arrangement to ensure continuity of care. In cases where hospital arrangements (includingadmitting privileges and membership) are not possible, health center must firmly establisharrangements for hospitalization, discharge planning, and patient tracking (Section 330(k)(3)(L)of the PHS Act).


Although DCHD/ACHC physicians do not have admitting privileges to area hospitals, there areagreements in place with local hospitals and hospitalist groups to provide inpatient care for

ACHC patients.

Recommendations: Performance improvement is in order.


Performance Improvement Area: Contracts and agreements.

Findings/Factors:

1. The agreement between DCHD/ ACHC and Cogent Healthcare, which provideshospitalist services at Shands Jacksonville Medical Center, does not have a date for

initiating service, and is signed by one party (DCHD). As written, the agreementappears to be a personal agreement between the Director of the Duval County HealthDepartment and Cogent Healthcare. It is not clear if the agreement as written extends toall clinical providers and patients in the DCHD/ACHC network.

2. The agreement between Duval County Health Department and Shands JacksonvilleMedical Center for specialty care does not have the signature of theauthorizing official atShands. According to the documentation, the agreement was to be renewed for one year;


14/38






14 of 38

however, the agreement has not been updated since 2004.

3. The agreement between St. Vincents Hospital and DCHD/ACHC only covers inpatientcare for obstetrical patients from the Wesconnett Family Medical Center and not theother clinic sites.

Recommendations:

1. DCHD/ ACHD needs to have service agreements that are properly signed by both partiesand have dates for start and end of service.

2. The agreement with Shands Jacksonville Medical Center for specialty care should bereviewed, updated, and properly signed

3. The agreement with St. Vincents Hospital for obstetrical care should be extended toDCHD/ ACHC patients from all locations.

4. An updated agreement with Shands Jacksonville Medical Center for obstetrical careshould be negotiated and implemented.

Program RequirementsProgram Requirement #7 - Sliding Fee Discounts: Health center has a system in place todetermine eligibility for patient discounts adjusted on the basis of the patients ability to pay.

This system must provide a full discount to individuals and families with annual incomesat or below 100% of the poverty guidelines (only nominal fees may be charged) and forthose with incomes between 100% and 200% of poverty, fees must be charged inaccordance with a sliding discount policy based on family size and income.*

No discounts may be provided to patients with incomes over 200% of the Federalpoverty level.*

(Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f))

Note: Portions of program requirements noted by an asterisk (*) indicate regulatory requirementsthat are recommended but not required for grantees that receive funds solely for Health Care forthe Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i))Programs.


The FQHC does not have signage indicating the availability of a sliding fee discount at the SouthJacksonville site, located at 3225 University Boulevard South.

Recommendations: The grantee must post signs communicating the availability of the slidingfee discount schedule for eligible low-income patients.


15/38






15 of 38


Performance Improvement Area: Sliding Fee Scale Discounts

Findings/Factors: Signage at the Agape Community Health Center, 1760 Edgewood AvenueWest, may not be appropriate for the literacy level of the patient population.

Recommendation: The grantee should consider simpler language to communicate theavailability of sliding fee scale discounts.

Program RequirementsProgram Requirement #8 -Quality Improvement/Assurance Plan: Health center has anongoing Quality Improvement/Quality Assurance (QI/QA) program that includes clinicalservices and management, and that maintains the confidentiality of patient records. The QI/QA

program must include: A clinical director whose focus of responsibility is to support the quality

improvement/assurance program and the provision of high quality patient care;*

Periodic assessment of the appropriateness of the utilization of services and the quality ofservices provided or proposed to be provided to individuals served by the health center;and such assessments shall: *

o Be conducted by physicians or by other licensed health professionals under thesupervision of physicians;*

o Be based on the systematic collection and evaluation of patient records;* ando Identify and document the necessity for change in the provision of services by the

health center and result in the institution of such change, where indicated.*(Section 330(k)(3)(C) of the PHS Act, 45 CFR Part 74.25 (c)(2), (3) and 42 CFR Part51c.303(c)(1-2)).

Note: Portions of program requirements noted by an asterisk indicate regulatory requirements thatare recommended but not requiredfor grantees that receive funds solely for Health Care for theHomeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i)) Programs.


ACHC has a comprehensive Quality Improvement (QI) plan that encompasses quality

performance measures, chart audits, scorecards, and data analysis. There is a three-tieredapproach to quality improvement. The Quality Assurance Circles (QAC) are comprised of threestaff members at each of the clinics on a rotating basis who perform chart audits and conductanalysis of the findings.The Network Clinical QI Committee consists of key managementpersonnel from ACHC and DCHD who review the reports from the QAC. The Executive QualityCommittee is comprised of the DCHD senior executive staff, who monitor trends across theDCHD. All three levels of quality committees meet monthly.


16/38






16 of 38

Findings:

1. There are no minutes documenting quality committee meetings.2. The Quality Improvement Planhas not been approved by the Board of Directors.

Recommendations:

1. Written minutes must be recorded for all quality committee meetings to reflect thediscussion, actions to be taken, identification of the person responsible for the action,and a timeframe for completion of actions.

2. The ACHC Board of Directors must approve the annual Quality Improvement Plan.Areas for Performance Improvement

Performance Improvement Area: Peer Review

Findings/Factors: Although peer review is conducted as part of chart audits (diseasemanagement, medication review, etc.), there is no formal peer review process.

Recommendations:

1. A formal peer review process should be developed. Peer review should be conducted asa separate function within QI activities.

2. All clinicians should undergo the peer review process on a regular basis or at least everysix months to ensure that standards of care are being met.


Performance Improvement Area:Clinical Guidelines

Findings/Factors: Clinical Guidelines were part of the DCHD Policies and Procedures Manual;however, the binder lacked organization, thereby making it difficult to readily access keyinformation. Guidelines for Womens Health were not signed as being approved. Family

Planning guidelines were very detailed (30+ pages). The chronic disease guidelines were fivepages, lacked specificity for diagnosis and treatment, and gave website references. The binder ofclinical guidelines in the clinic area contained specific guidelines for Diabetes, Hypertension,Asthma, Coronary Heart Disease, Chronic Kidney Disease, Chronic Obstructive PulmonaryDisease, Pneumonia and Prenatal Care that were complete documents for diagnosis andtreatment.

Recommendations:

1. Organize the Clinical Policies and Procedures Manual to include guidelines for the mostcommon diseases of patients seen by providers in each clinical department and developspecific, detailed, and evidence-based guidelines for each diagnosis. Place a table ofcontents and/or tabs in the manual for quick reference.

2. Place a printed copy of the Clinical Policies and Procedures manual in each clinical area


17/38






17 of 38

for easy access to guidelines by clinicians and other staff. Provide the complete manualon a shared computer drive for staff retrieval.

3. Review and update clinical guidelines on a regular or as-needed basis.


18/38






18 of 38

SECTION 3: Management and FinanceProgram Requirements

Program Requirement #9 - Key Management Staff: Health center maintains a fully-staffed

health center management team as appropriate for the size and needs of the center. Prior reviewby HRSA of final candidates for Project Director/Executive Director/CEO position is required(Section 330(k)(3)(H)(ii) of the PHS Act and 45 CFR Part 74.25 (c)(2), (3)).


It is a requirement that the governing board have the authority to hire and fire its CEO.This person must be responsible to the governing board for meeting the goals and objectivesestablished by the governing board as part of the centers strategic plan and a contract with the

CEO regarding her performance. In the October 2004 agreement between the Duval CountyHealth Department and the governing board, the role of the board in this area was limited toapproval of the selection and dismissal of the Executive Director of the Health Center.

Furthermore, the administrative, financial management, billing and human resources functionsare provided by the Duval County Health Department. This not-unexpected arrangementappears to fully meet the needs of the staff and patients in all of ACHCs five sites. However,

it should be noted here that, in this arrangement, the E.D. does not have any responsibility forthe DCHD staff who provide these servicesas would be expectedand, more surprisingly,she no longer has any staff who report to her. This latter fact is in clear contradiction with theorganizational chart, which misleadingly shows that the E.D. has direct supervisoryresponsibility for 29 staff, including several DCHD employees.

The CFO position has been vacant for six months but a new employee has been engagedeffective July 1, 2012. The new employee holds a Bachelors degree in accounting, is enrolledin an MBA Finance program, and has relevant experience in the private and public sectors.During the period of vacancy in the CFO position, the DCHD Assistant Director, Administrationand Operations, served as Interim CFO.

Recommendations: It is required that a contract be developed and signed by members of thegoverning board and the CEO to assure that this individual reports to and is held accountable tothe board of the health center and not the Duval County Health Department. This contract mustmake it clear that the CEO has the authority to operate the health center, managing all aspects ofits operation including the budgetary process, personnel issues and programmatic issues as theyarise. The CEO would have authority for executing budgetary decisions, hiring and firing staff,and allocating resources.

The co-applicant provision in section 330(k)(3)(H)(ii) recognizes that public agencies may beconstrained by law in the delegation of certain government functions to private entities, and thuspermits the public agency (i.e. the Duval County Health Department) to retain authority overgeneral policies for the public center. Thus, in the case of public center grantees with co-applicant governing boards, the public center is permitted to retain authority for establishing


19/38






19 of 38

fiscal and personnel policies for the health center. The co-applicant agreement must describethe delegation of authority and define roles, responsibilities, and authorities of each party in theoversight and management of the health center.

The health center board and the Duval County Health Department should develop operationalguidelines beyond the co-applicant agreement for sharing roles and responsibilities so thatit is clear that compliance with program requirements is being practiced operationally. It isrecommended that the Health Department and board secure a facilitator to assist in appropriatelyimplementing the required and shared authorities in their existing co-applicant agreement andperhaps develop a grievance/resolution process. BPHC should be contacted for additionaltechnical assistance in this matter.


Performance Improvement Area: 1) Administrative and other services agreement; 2)

organizational chart; 3) key management staff.

Findings/Factors:

1. There is no up-to-date written agreement between ACHC and the Duval County HD thatclearly states what infrastructure is being provided to the health center and, moreimportant, at what expense.

2. As stated above, the health centers organizational chart does not accurately represent theactual situation in regards to the E.D.s supervisory responsibilities. This is not the onlyexample that was encountered of a document not accurately or completely reflecting theactual situation it is supposed to be describing.

3.

The assessment team noted some breakdowns in communication, particularly withrespect to financial management. For example, the E.D. was unaware of the unobligatedbalance in the IDS grant. In addition, the E.D. reported that she had not participated inany discussions about budget strategies to ensure that grant funds are fully expended.

Recommendations:

1. The E.D. and board of directors should insist on having a formal written agreement withthe Duval County HD that clearly states what infrastructure is being provided to thehealth center and how that cost to ACHC is calculated. This agreement should beattached to an updated co-applicant agreement.

2. The organization chart should be corrected immediately to reflect what the true lines ofsupervision are, specifically who reports to the E.D. At the same time, the E.D.s jobdescription should be reviewed and updated to accurately describe what herresponsibilities, duties, and expectations are so that it can be used as a document that


20/38


21/38






21 of 38

discussion items. For example, the agreement should describe a role for the Board to reviewcompliance with Bureau of Primary Health Cares nineteen program requirements. As a resultof the assessment visit, the grantee will develop a corrective action plan. The agenda shouldprovide time for the Board to review the status of each corrective action item and provide input.

The minutes should summarize the Boards discussion and any action taken regarding thecorrective action plan.

Program Requirements

Program Requirement #11 - Collaborative Relationships: Health center makes everyreasonable effort to establish and maintain collaborative relationships with other health careproviders, including other health centers, in the service area of the center. The health centersecures letter(s) of support from existing Federally Qualified Health Center(s) in the service areaor provides an explanation for why such letter(s) of support cannot be obtained (Section330(k)(3)(B) of the PHS Act).


ACHC has MOUs with mental health and substance abuse providers to mutually accept eachothers referrals; an agreement with the Department of Obstetrics and Gynecology, College ofMedicine-Jacksonville, University of Florida agreement through the DCHD for labor anddelivery services; and agreements with St. Vincents Ambulatory Care, Inc., to provide hospitalfunding for clinic staff at the Wesconnett CHC site to help reduce unnecessary ER visits and toprovide hospital funding for the mobile unit, again through the DCHD. There is also anotherFQHC in Jacksonville, the Sulzbacher Center, which is a homeless program with which theExecutive Director has established an informal relationship to cooperate in mutually beneficialendeavors. These do not involve any clinical program activities at this time, such as referrals of

patients and clients.



Performance Improvement Area: None.

Findings/Factors: N/A

Recommendations: N/A


Program Requirement #12 - Financial Management and Control Policies: Health centermaintains accounting and internal control systems appropriate to the size and complexity of theorganization reflecting Generally Accepted Accounting Principles (GAAP), and separatesfunctions appropriate to organizational size to safeguard assets and maintain financial stability.Health center assures that an annual independent financial audit is performed in accordance with


22/38






22 of 38

Federal audit requirements, including submission of a corrective action plan addressing allfindings, questioned costs, reportable conditions, and material weaknesses cited in the AuditReport (Section 330(k)(3)(D), Section 330(q) of the PHS Act and 45 CFR Parts 74.14, 74.21 and74.26).


As part of the Florida Department of Health, DCHD is subject to the statewide financialpolicies which provide detailed guidance on the accounting system, fund accounting, budgetmanagement, contract and grant management, revenue and cash management. The stateaccounting system operates on a cash basis during the fiscal year but records journal entries atcloseout to present financial statements on a modified accrual basis.

For the purpose of monthly reports on the FQHC, the DCHD uses its internal subsystem tocapture receivables, payables, and accrued salaries.Internal control is strengthened by the requirement that all transactions are reviewed andapproved at the levels of the FQHC, the DCHD, and the Florida Department of Health.

The State of Florida Auditor General fulfills the requirements of the Office of Management andBudget Circular A-133,Audits of States, Local Governments, and Non-Profit Organizations.The auditor expressed an unqualified opinion on the financial statements for the fiscal yearending June 30, 2010. The A-133 audit for the same period noted no material weaknesses,reportable conditions, or instances of noncompliance pertaining to the primary care servicesprovided by local health departments.

With respect to cash management, the Florida Department of Health requires the county healthdepartments to maintain a cash reserve of 7-9.5% of quarterly expenditures. The cash balance onhand as of May 31, 2012 meets this requirement.






Program Requirement #13 - Billing and Collections: Health center has systems in place tomaximize collections and reimbursement for its costs in providing health services, includingwritten billing, credit and collection policies and procedures (Section 330(k)(3)(F) and (G) of thePHS Act).



23/38






23 of 38

As part of the Florida Department of Health, DCHD is subject to the statewide policies governingCounty Health Department accounts receivables. The policies provide detailed guidance on theauthority to charge fees, management of the accounts receivable system, recording services, cashreceipts, third party billing, contractual adjustments, write-offs and debt collections, payment plans

and management reports.

The grantee prepares and monitors detailed monthly reports of accounts receivable, includingaged accounts receivable by payer and by site, denied claims, no-show activity, etc. In addition,the Executive Director and the DCHD Clinic Operations Manager monitor the daily error reportsand conduct detailed reviews of practice management activities.

It is noteworthy that the FQHC is able to receive the cost-based Medicaid reimbursementapproved for DCHD, which is currently $151.42/encounter. This rate is more favorable than theFQHC prospective rate of approximately $114/encounter.







Program Requirement #14 - Budget: Health center has developed a budget that reflects thecosts of operations, expenses, and revenues (including the Federal grant) necessary toaccomplish the service delivery plan, including the number of patients to be served (Section330(k)(3)(D), Section 330(k)(3)(I)(i), and 45 CFR Part 74.25).


The minutes of the Board do not include evidence that the Board approved the budget.In addition, the minutes do not indicate that the Board discussed any budget strategies duringthe prior year when the monthly financial reports identified material variances from the budget(either under spending or overspending.)

The Executive Director has the ultimate responsibility for the FQHC budget but the DCHDfinance staff is responsible for the daily operation and corrective action. The Executive Directoris not fully engaged in the budget management system. As noted above, the Executive Directorwas unaware of the unobligated balance in the IDS grant. The financial reports for the periodJanuary 1, 2012, through May 31, 2012, identify a favorable budget variance of $18,329, but theExecutive Director has not discussed the status of the budget with the Board or with the DCHDfinance staff.


24/38






24 of 38

Recommendations: The grantee must establish a process whereby the budget is developedwith input from the Board, is formally presented to the Board, and is approved/disapproved byvote of the Board. The Board must review the financial reports and consider options for budgetstrategies when material variances occur. All discussions and actions must be recorded in the

minutes of the Board meetings.

The grantee must strengthen accountability and communication systems between the ExecutiveDirector and the DCHD finance staff. The co-applicant agreement must include provisions torequire appropriate accountability and communication systems, including delineation of theresponsibilities for budget development, budget approval, budget monitoring, and budgetmanagement. The Executive Director should take a more active role in recommending andimplementing budget strategies to control budget variances (either under spending oroverspending.) She should participate meaningfully in regular management meetings to developand monitor the budget. She should improve her understanding of the budget managementfunctions by studying the financial documents and asking questions when necessary.






Program Requirement #15 - Program Data Reporting Systems: Health center has systemswhich accurately collect and organize data for program reporting and which support managementdecision making (Section 330(k)(3)(I)(ii) of the PHS Act).


The strategic plan for the Agape Community Health Network presents the strategy for the period2009 through 2013. The plan includes mission and vision statements and the analysis ofstrengths, weaknesses, opportunities, and threats. The strategic goals are:

Develop a strategic plan that will address the ongoing, fluid issues associated with theidentified target market and issues that may affect/present as barriers to access to care.

Eliminate barriers to access to care. Enhance patient access to care via payer insurance carrier coverage while generating

greater revenue streams.

The strategic plan does not demonstrate that data reporting and needs assessments were used toinform and support the planning decisions. There was no evidence presented to indicate that thestatus of the plan was assessed or updated during the planning horizon, even though the firstobjective and action item call for periodic review by the Board. The Executive Directors


25/38






25 of 38

performance evaluation form indicates that the strategic plan has not been connected to the planfor the DCHD; that business plans have not been developed; and that the Board has not held itsplanning retreat.

Recommendations: The grantee must develop a strategic plan that uses information from thedata reporting and needs assessments to inform and support the plan. In addition, the granteemust ensure that the status of the goals and objectives is monitored periodically.


Performance Improvement Area: Program Data Reporting System

Findings/Factors: The grantees systems for collecting and organizing the data required for theUDS require collaborative work from the Executive Director and the DCHD staff.

Recommendations: The grantee should consider improvements to the process such as a writtenwork plan specifying tasks, person(s) responsible and deadlines; the status of the work planshould be monitored in team meetings. In addition, the grantee should establish and follow amanagement calendar that identifies the start dates and necessary lead times for the various tasks.


Program Requirement #16 - Scope of Project: Health center maintains its funded scope ofproject (sites, services, service area, target population and providers), including any increasesbased on recent grant awards (45 CFR Part 74.25).


DCHC maintains its funded Scope of Project (sites, services, service area, target population andproviders) as stated on Form 5A.







26/38






26 of 38

SECTION 4: GovernanceProgram Requirements

Program Requirement #17 - Board Authority: Health center governing board maintains

appropriate authority to oversee the operations of the center, including: Holding monthly meetings; Approval of the health center grant application and budget; Selection/dismissal and performance evaluation of the health center CEO; Selection of services to be provided and the health center hours of operations; Measuring and evaluating the organizations progress in meeting its annual and long-term

programmatic and financial goals and developing plans for the long-range viability of theorganization by engaging in strategic planning, ongoing review of the orga nizationsmission and bylaws, evaluating patient satisfaction, and monitoring organizational assetsand performance;* and

Establishment of general policies for the health center.(Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304)

Note: In the case of public centers (also referred to as public entities) with co-applicantgoverning boards, the public center is permitted to retain authority for establishing generalpolicies (fiscal and personnel policies) for the health center (Section 330(k)(3)(H) of the PHSAct and 42 CFR 51c.304(d)(iii) and (iv)).

Note: Upon a showing of good cause, the Secretary may waive, for the length of the projectperiod, the monthly meeting requirement in the case of a health center that receives a grantpursuant to subsection (g), (h), (i), or (p) (Section 330(k)(3)(H) of the PHS Act).

Note: Portions of program requirements noted by an asterisk* indicate regulatoryrequirements that are recommendedbut not requiredfor grantees that receive funds solely forHealth Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section330(i)) Programs.


A review of board of directors meeting minutes for the 25 months beginning March 2010through March 2012 showed the following:

No meetings held in March, April, May and September 2010 or June, July, Septemberand December 2011;

No minutes for June and July 2010 and February 2011 meetings, if they took place at all; Of the fourteen meetings (including those conducted by conference call, which should be

the exception and not the usual practice) that did take place, ten did not have a quorum ofat least six members.

Furthermore, there is no mention in any minutes that would support the contention that the boardreviews and approves the annual budget for the Agape Community Health Center. Also,although the board members interviewed say that the board has input in the Executive Directors


27/38






27 of 38

annual performance evaluation, there is no place on the evaluation form that was reviewed by theconsultant for the dated signature of the ACHC board chairman or any other officer of the board.The current co-applicant agreement says only that the ACHC board has approval of theselection and dismissal of the Executive Director of the Health Center and does not mention any

role in her performance evaluation. These situations underline how the board has relinquishedkey aspects of its responsibilities as a health center board of directors to the Health Department.

Recommendations: The board of Agape CHC must immediately ensure that monthly boardmeetings are held; that there is a quorum at each meeting; and that proper and complete minutesfor each meeting are recorded and made part of the file. Furthermore, the BOD must assume itsrightful and required role in the on-going supervision of the Executive Director, and this must bemade clear in any new co-applicant agreement. Last, the board must acknowledge itsresponsibility in being fully informed on any programmatic and financial plans for the healthcenter. This responsibility is expressed and discharged through reviewing, critiquing, amendingand, finally approving, any grant application, proposed contract and budget, including and

especially the annual operating and capital budgets. The next important opportunity to do so isthe Strategic Area Competition grant application that is due in August 2012. The SACapplication must be reviewedin its entiretyand approved by the ACHC board before it issubmitted, and this action must be recorded in the board meeting minutes.


Performance Improvement Area: 1) Documentation of a cancelled board meeting; 2)

enforcement of by-law to remove non-active board members; 3) board training.

Findings/Factors:

1. It was unclear whether the meetings for June and July 2010 and February 2011 were held,or if the minutes for those meetings are just missing.2. There is a by-law that requires the removal of board members who have three unexcused

absences. There were two board members who did not attend any of the 14 boardmeetings that were held between March 2010 and March 2012 either in person or bytelephone. Another attended only two, and a fourth attended only five board meetings inthat span. For this reason, each of the other six members would have had to attend everymeeting in order to assure a quorum.

3. The meeting with the board minutes indicates that, while there is energy and commitmenton the part of a small core group, the board as a whole would benefit from receivingtraining that would allow it to better understand its roles and responsibilities as a

governing body, especially in its interface with the Duval County Health Department.

Recommendations:

1. If a meeting is not held for whatever reason, there should be a clear indication in theboard meeting minutes binder that there was no meeting.

2. As mentioned above, there were ten meetings between March 2010 and March 2012 thatdid not have a quorum of members, and another three meetings were cancelled altogether


28/38






28 of 38

because a quorum would not be in attendance. Because a quorum is necessary in order toconduct business in fullmost especially any agenda item that requires a votetheACHC board should enforce the by-law that requires the removal of board members whohave three unexcused absences and instruct the Membership/Nominating Committee to

recruit suitable replacements who will be able to attend meetings on a regular basis.3. The executive committee of the board should conduct a board training needs assessment

and then discuss with the E.D. what resources might be available to provide technicalassistance and trainingthe Florida Association of Community Health Centers and theBureau of Primary Health Care being two that come immediately to mindto assist themembership in understanding and even defining the boards roles and responsibilities

within the current framework that includes DCHD. (If it is agreed that a request for thistype of assistance from BPHC is appropriate, it can be communicated to ACHCs ProjectOfficer.


Program Requirement #18 - Board Composition: The health center governing board iscomposed of individuals, a majority of whom are being served by the center and, who, as agroup, represent the individuals being served by the center in terms of demographic factors suchas race, ethnicity, and sex. Specifically:

Governing board has at least 9 but no more than 25 members, as appropriate for thecomplexity of the organization.*

The remaining non-consumer members of the board shall be representative of thecommunity in which the center's service area is located and shall be selected for theirexpertise in community affairs, local government, finance and banking, legal affairs,

trade unions, and other commercial and industrial concerns, or social service agencieswithin the community.*

No more than one half (50%) of the non-consumer board members may derive more than10% of their annual income from the health care industry.*

Note: Upon a showing of good cause, the Secretary may waive, for the length of the projectperiod, the patient majority requirement in the case of a health center that receives a grantpursuant to subsection (g), (h), (i), or (p) (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part51c.304).

Note: Portions of program requirements noted by an asterisk(*) indicate regulatory requirementsthat are recommendedbut not requiredfor grantees that receive funds solely for Health Care forthe Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i))Programs.


Only five of the ten board members or members of their immediate families have been users ofthe health centers services in the previous 24 months.


29/38






29 of 38

Recommendations:The boards Membership/Nominating Committee must start immediately toidentify and recruit appropriately qualified current users of the health centers services to serveon the board and act in accordance with their own by-laws and remove members for meetingnonattendance. 51% of the Board must be patients of the health center.


Performance Improvement Area: Board member expertise.

Findings/Factors: There are several key areas of expertise that are not currently represented onthe board.

Recommendations: At the same time that the board is removing non-active members andrecruiting from the health centers user base, it should try to find new members with experienceand expertise in health care, finance, marketing, insurance and fund-raising, among other areas,

and who are of Latino ethnicity or Caucasian, categories that are under-represented on the board.


Program Requirement #19 -Conflict of Interest Policy: Health center bylaws or writtencorporate board approved policy include provisions that prohibit conflict of interest by boardmembers, employees, consultants and those who furnish goods or services to the health center.

No board member shall be an employee of the health center or an immediate familymember of an employee. The Chief Executive may serve only as an ex-officio member ofthe board.*

(45 CFR Part 74.42 and 42 CFR Part 51c.304(b))

Note: Portions of program requirements noted by an asterisk(*) indicate regulatory requirementsthat are recommendedbut not requiredfor grantees that receive funds solely for Health Care forthe Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i))Programs.


Although there is a written conflict of interest policy covering the board of directors in theorganizations by-laws, there are no statements signed by the board members attesting to theirnot having any COI or divulging any potential or actual COI which would require them to recusethemselves from participating in any discussions or from voting on any matters related to theCOI.

Recommendations: Each member of the board of directors must immediately provide writtendocumentation that (s)he does not have any conflict of interest in any matters related to thehealth center, or disclose what that COI is, actual or potential, if it does exist. The ExecutiveDirector has stated that she has distributed COI forms to be signed by the board membership


30/38






30 of 38

for the first time during her tenurebut has not received any back. The signed and completedforms need to be kept on file and available for review upon request by authorized parties.






31/38






31 of 38

SECTION 5: Clinical Performance Measures (see Appendix C of Health Center Site Visit

Guide for additional information on required measures)Areas for Performance Improvement

Selected Performance Measure #1: Percentage of adult patients with diagnosedhypertension whose most recent blood pressure was less than 140/90.

This measure was selected because hypertension is the most common diagnosis among ACHCpatients. The percentage of patients with blood pressures less than 140/90 has trended down by17% in the last year. The goal stated in the Clinical Performance Measures attached to the 2012application is the same as the 2010 base year (58.57%).

2009 2010 2011

54.29% 58.57% 41.4%

Healthy People 2020 =62%Data from 2010 UDS Health Center Trend Report and 2011 UDS Report

Contributing Factors are:

The Hospital Emergency Room Alternatives Program (HERAP) provides diseasemanagement and self-education management to patients.

Prescription assistance programs provide no cost medications to patients. Treatment of co-morbidities, which can improve blood pressure Medication review by clinical pharmacists at Agape and Wesconnett Health Centers

Restricting Factors are:

Patient resistance to taking medications and subsequent low compliance Loss of R.N. who performed many of the QI activities, including chart audits and

monitoring of clinical performance measures

Providers are not placing hypertensive patients on diuretics.Recommendations:

Continue patient education utilizing the clinical pharmacist as part of the health careteam.

Select a qualified clinical staffer to perform and supervise data collection and analysis ofclinical performance measures.

Conduct an in service training session for treatment of hypertension including use ofdiuretics.


32/38






32 of 38


Selected Performance Measure #2: Percentage of women 21-64 years of age who receivedone or more Pap tests to screen for cervical cancer.

Findings/Factors: This measure was selected due to the significant decline in the Pap smearrate. A trend cannot be stated due the 2010 percentage, which varies widely from the 2009 and2011 percentages of Pap smears. The goal stated in the Clinical Performance Measures attachedto the 2012 application is the same as the 2010 base year (94.29%). The 2010 percentage is anaberrant percentage which needs to be verified and/or corrected.

2009 2010 2011

45.71% 94.29% 25.71%

Data from 2010 UDS Health Center Trend Report and 2011 UDS Report

Contributing factors are: Female nurse practitioners perform the majority of Pap smears. Pap smears of female patients who are enrolled the Medicaid Managed Care Program are

closely tracked and the clinic is notified that a Pap has not been performed.

Restricting factors are:

Loss of R.N. who performed chart audits and monitored clinical performance measures. Change in practice guidelines and inconsistent data collection and interpretation. Missed opportunities to perform Pap smear by scheduling patient to return for Pap test

instead of performing test while patient is present in clinic.

Recommendations:

Re-examine data for the last three years to verify the percentage of Pap smears performedand also explain the large variance in yearly percentages.

Appoint a qualified staff person to supervise chart audits and monitor clinicalperformance measures.

Monitor Pap smears as a performance improvement measure on a consistent basis,utilizing the new guidelines.

Perform Pap smears when needed and do not re-schedule patients to return for Pap. Request technical assistance on how to report data for the required clinical performance

measures.


33/38






33 of 38

SECTION 6: Financial Performance Measures (see Appendix C of Health Center Site Visit

Guide for additional information on required measures)Areas for Performance Improvement

Selected Performance Measure #1: Total cost per patient

2009 2010 2011

Total accrued cost before donations and afterallocation of overhead (Table 8A, line 17, column c)

$6,265,459 $6,769,920 $6,718,482

Total number of patients (Table 4, line 6, column a) $25,814 $25,173 $30,063

Total cost per patient $242.72 $268.94 $223.48

As noted in the UDS reports, the federally approved indirect cost rate for the State of Floridachanged during the period 2009 through 2011. The fluctuation in the rate contributed to thechanges in the total cost per patient. In addition, the Florida Department of Health improved the

accuracy of the square footage allocations in 2010, which contributed to the changes in total costper patient from 2010 to 2011.

Medical cost per medical visit

2009 201