What Have We Learned About Safety Net Providers and Integrated Care?

Elderly woman prepares to get a flu shot at a community clinic, photo by SDI Productions/Getty Images

Community health centers (CHCs) are organizationally independent health care providers that offer primary care to vulnerable and low-income U.S. residents (about 27 million patients annually) regardless of their ability to pay, and many CHC patients have complex medical conditions and a high need for social services. CHCs receive higher reimbursements from Medicare and Medicaid to support these populations, and most centers receive funding through the Health Resources & Services Administration (HRSA) Health Center Program.

Historically, many CHCs have struggled to secure access to hospitals and specialty services for their patients and to ensure adequate communication among providers. Unlike other types of physician organizations that have rapidly joined large health systems, most CHCs maintain only informal connections with other local health care providers and health systems. However, the expansion of new delivery models and value-based payment systems are providing new incentives for safety net providers to develop more integrated systems of care.

Researchers from the RAND Center of Excellence on Health System Performance examined strategies that CHCs use to achieve greater integration with three types of service providers (specialists, hospitals, and social service organizations) and assessed how the strategies affect quality of patient care and communication with other health care providers. Their goal was to understand whether the strategies actually promote better integrated care and to determine whether integration was associated with the provision of evidence-based care.

These studies draw on administrative data (from the Health Resources & Services Administration’s Health Center Program) and a web-based survey of the medical directors at CHCs in 12 states and the District of Columbia. The research team focused on states with active Medicaid accountable care organizations (ACOs) because ACOs may promote greater accountability for providing more coordinated care. Five additional states and D.C. were included in the sample to improve geographic diversity and to make sure that the sample included states that expanded Medicaid under the Affordable Care Act and those that did not.

Two hundred and fifteen CHC medical directors (slightly more than half) responded to the survey. On average, these medical directors represent CHCs that serve about 24,400 patients annually, primarily in urban communities. About one-fifth of CHC patients served in these centers were uninsured, more than half were enrolled in Medicaid, and about 60 percent were racial or ethnic minorities.

In brief, we learned:

  • CHCs differ in their use of strategies to integrate care with hospitals. Overall, integration activity is associated with better communication among providers.
  • Efforts to promote integration with specialists may increase rates of cancer screening in CHCs.
  • Some CHCs provide social services on-site; this approach is associated with better performance on a composite measure of health care quality.

CHC Efforts to Promote Integration Foster Better Communication With Hospitals

Empty room in a hospital, photo by alvarez/Getty Images

Photo by Tyler Olson/Fotolia

To better meet patient needs, CHCs collaborate with hospitals—for example, sharing electronic health records, coordinating across care settings, and connecting emergency department (ED) patients to primary care sources. Many centers also participate in ACO programs, which encourages coordination between primary care providers and hospitals.

However, CHCs often find it difficult to work with hospitals, including safety net hospitals: the CHC mission is to provide primary care services to predominantly indigent populations, while hospitals often serve a more economically diverse population. The difficulties that CHCs and hospitals confront in sharing health information also hinder integration.

What integration strategies are CHCs using?

This study examined the prevalence of five different CHC strategies to integrate care with hospitals and their emergency departments (EDs).

Strategy to Integrate Care with Hospitals Percent of CHCs Using the Strategy
Participate in joint meetings with hospital leadership 81
Align practice guidelines or protocols that hospitals use 62
Participate in quality improvement projects with hospitals 61
Participate in health promotion initiatives with hospitals 57
Notification agreements
About hospital admissions 34
About ED visits 31

The most common strategies were meeting with hospital leadership, participating in quality improvement efforts, and aligning practice guidelines or protocols with hospitals. Only about one-third of hospitals were able to establish notification agreements to improve care transitions; more than half had tried but failed to establish such an agreement.

CHCs that reported more integration activities had more patients, more sites, and more staff. Centers operating in competitive markets or in states with active ACO programs were also more likely to actively focus on integration. Integration was less likely in CHCs that had a larger share of minority patients, chaotic practice environments, and staff shortages.

How did integration activity affect CHC-hospital communication?

To estimate how the level of integration activity affected communication, the research team used five self-reported communication measures:

  • CHC is notified that patient has been admitted to the hospital
  • CHC is notified after the patient is discharged from the hospital
  • CHC receives discharge summaries from the hospital
  • Hospital discharge summaries have all the information needed for follow-up care
  • CHC receives summaries from hospitals when needed.

For analysis, the research team sorted CHCs’ level of integration activity into three tiers, then examined the mean scores for reported communication in each tier. Overall, CHCs in the top tier of integration activity had significantly higher performance on measures of communication than centers in the lowest tier. The largest difference was the frequency with which health centers received discharge summaries from hospitals and the completeness of discharge summaries. The team also found large differences between tiers on measures of communication with hospital emergency departments.

Efforts to Promote Integration with Specialty Care Providers May Improve Rates of Cancer Screening in CHCs

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Photo by FatCamera/Getty Images

CHCs can help to increase cancer screening rates for the ethnically diverse and economically disadvantaged populations whom they serve. However, CHC providers often find it difficult to obtain specialty care for their patients when needed.

What strategies are CHCs using to integrate with specialists?

This study examined the prevalence of the following strategies:

Strategy to Support Integration with Specialty Care Providers Percent of CHCs Using the Strategy
Improving referrals
Establishing referral agreements 71
Participating in e-consults 59
Making specialists appointments for patients 44
Reminding patients about the appointment 36
Aligning goals with specialists
Quality improvement projects or health promotion activities with specialists 71
Information exchange
Send data electronically to specialists 26
Read specialists’ EHRs in real time 25
Improving access to specialty care
Providing specialty care on site 81
Expanding telemedicine 29
Developing affiliations with hospitals to obtain timely specialty care for patients 41

The most commonly used strategy was having specialists provide care on-site at the CHC (81%); CHCs also commonly reported aligning goals with specialists through QI health promotion activities (71%) and establishing agreements with specialists about the types of information they would exchange (70%).

The research team also created a composite measure of CHC/specialist integration and used this measure to categorize CHCs as having high, medium, or low levels of integration with specialists. CHCs that were most integrated with specialists were consistently more likely to report activities designed to promote integration – for example, making appointments for patients.

How is CHC/specialist integration related to cancer screening rates?

The team also identified an association between CHC/specialist integration and the five measures of CHC/specialist communication.

Predicted probabilities of measures of CHC/specialist communication by tertile of CHC/specialist integration

Communication Type Adjusted predicted probability
Lowest Medium Highest
CHC knew that specialist visit happened 41.8% 54.6% 66.5%
CHC knew outcome of specialty visit 41.7% 49.5% 64.6%
CHC received clear recommendations following specialist visit 20.5% 36.1% 46.7%
CHC received results/recommendations from specialist in a timely manner 26.6% 32.9% 43.7%

Note: We use four items related to CHC/specialist communication as dependent variables to indicate if the CHC “often” or “always” (1) knew that a specialist visit happened, (2) knew the outcome of a specialty visit, (3) received clear follow-up/care management recommendations following the specialist visit, and (4) received results/recommendations from the specialist in a timely manner. Each item was dichotomized based on the empirical distribution of responses (reference group combined responses of “never,” “rarely,” and “sometimes”).

By increasing integration with specialists ... CHCs have the potential to decrease disparities in cancer screening.

On every communication measure, CHCs that were most integrated with specialists had significantly higher levels of communication than the least integrated CHCs. For example, 65% of CHCs in the highest category of integration knew that a specialist visit had taken place compared with 42% of CHCs with the lowest integration. The biggest differences across levels of integration were the extent to which CHCs received clear recommendations for follow-up care after a specialty visit and the extent to which the CHCs knew that a specialty visit had taken place.

Good communication between CHCs and specialists is essential for any screening effort. CHCs that are not well integrated might not receive results of screening tests and lack the information they need to determine follow-up care. CHCs treat patients who are racially/ethnically diverse and economically disadvantaged. By increasing integration with specialists, thus improving overall communication with them, CHCs have the potential to decrease disparities in cancer screening.

CHCs that Offer Social Services On-Site Have Better Scores on Quality Measures

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Social determinants of health (SDOH), which may explain up to 80% of the differences in population health, have become a major focus in primary care. CHCs serve populations with high social needs and are an ideal environment in which to address SDOH. CHCs are more likely than other providers to screen for SDOH, and some CHCs provide social services on-site.

Drawing on both survey and administrative data, the research team determined how many CHCs provided social services on-site (as compared to those who referred patients to services in the community), the types of services involved, and the CHC characteristics associated with providing on-site services. The team also explored the association between providing on-site services and CHC performance on an aggregate measure of health care quality.

The survey asked about CHC efforts to address eight social needs, including employment, housing, utilities, food or nutrition, child care and early education, non-medical transportation, employment, and interpersonal violence.

What social services are CHCs providing?

Overall, CHCs were more likely to refer patients to social services rather than to provide services on-site. About 35 percent of CHCs did not provide any social services on-site, but nearly all CHCs reported referring patients for at least one social service. About two-thirds of the CHCs in the study provided at least one social service on-site – most commonly helping with nutrition, interpersonal violence, and housing. CHCs were more likely to provie at least one on-site service if they participated in meetings with community-based organizations, had higher staffing levels, and had a large patient population.

Percentage of community health centers (CHCs) that provide each of eight social services by referral or on-site

Social service Provide services on-site Refer patients to another organization
Assistance with childcare / early education 11% 77%
Assistance with immigration issues 14% 62%
Assistance with employment 14% 67%
Assistance with paying utility bills 16% 69%
Assistance with non-medical transportation 24% 61%
Assistance with housing 30% 64%
Assistance for victims of interpersonal violence 32% 74%
Assistance with nutrition / WIC needs 43% 58%

Note: Respondents were permitted to select both response options (i.e., refer patients to another organization and provide services on-site). Thus, the denominator for each bar is the total number of survey respondents (n=208). CHCs were more likely to report referring for each service than to report providing each service on-site (p-values from all eight chi-square tests were <0.01). WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Does CHC provision of social services affect health care quality?

On-site provision of social services was associated with higher performance on an aggregate measure of health care quality. Each additional social service offered on-site was associated with a 0.03 increase in a CHC’s quality score. In other words, a CHC providing three social services on-site (compared with no social services) would be associated with a 4.3 and 3.8 percentage point increase in rates of colorectal and cervical cancer screenings (from means of 40% and 51%, respectively).

Providing social services on-site may not be the best solution for all health care providers, and resource constraints make on-site services beyond the reach of many CHCs. However, CHCs, like other health care providers, are increasingly attentive to addressing social determinants of health. CHCs have historically been a bridge to services provided by community organizations, but increasingly, CHCs are attempting to provide services directly to increase delivery of social services and reap the associated benefits to quality of care.

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