A Clinically Integrated Network
Community Care of NC Innovation
Forum
January 13th, 2015
Course Objectives:
Participants will understand what
a Clinically Integrated (CIN) is
and the role they will play in
health care reform.
Participants will understand and
be able to discuss different
perspectives on health reform
and CINs – primary care, safety
net providers and hospitals.
Clinical Integration Defined
• A network of physicians working collaboratively to
improve the quality and efficiency of patient care – led
by physicians and supported by a population health
management infrastructure (CCNC).
• To be the health care delivery solution for “all” systems
by demonstrating value and quality of care.
• Physicians are the leaders in the development of all
facets of the program.
• Facilitating the delivery and coordination of patient
care across conditions, providers, settings and time.
• Focusing on patient populations.
Vision and Principles
• Several provider organizations, in an effort to better
serve the needs of their members, have requested that
CCNC help support the development of a Clinically
Integrated Network (CIN) demonstrating enhanced
quality, efficiency and access to health care services.
• Participating providers must demonstrate commitment
to improving the qualify of care for their patients.
• Starting with primary care providers but will add
aligned specialists and hospitals interested in
improving health outcomes and moving towards a
value-based model.
Unenrolled
355,413
Established
Provider-led
ACO’s
73,887
Other
(RHC, LHD, other)
96,226
FQHC
100,800
CCNC Medical Home
Network: Where are
Medicaid Beneficiaries
Seen?
Independents
644,602
Other
Hospital Owned
120,869
Large
Health System
Owned
344,655
5
*Numbers represent estimated number of members enrolled in each type of practice (total member months divided by 10).
Who Provides Primary Care Medical Homes for NC Medicaid Recipients?
Large Health System Owned Practices
Other Hospital Owned Practices
6
7
Initial Steps in the Formation of the CIN:
• Network Name and Logo
• Geographic Coverage
– State-wide (with potential for regional contracts)
• Legal Structure
– LLC – Limited Liability Company
• Provider Relations and Recruitment Effort
– Marketing material
– Letter of Intent
– Participation Agreement
• Initial Governing Board Members Identified
Initial Governing Board Identified
• Dr. Deborah L. Ainsworth, FAAP
• Mr. Charles. T. Frock, MHA
• Dr. Stephen Hsieh
• Mr. E. Benjamin Money, Jr., MPH
• Dr. Joe Ponzi
• Dr. Thomas R. White
• Dr. Kerry Willis
Panelists:
• Deborah L. Ainsworth, MD, FAAP
– Chapter President, North Carolina Pediatric Society
• Charles T. Frock, MHA
– Former Chief Executive Officer, FirstHealth of the Carolinas
• E. Benjamin Money, Jr., MPH
– President and CEO, North Carolina Community Health Center
Association
• Thomas R. White, MD
– President, North Carolina Academy of Family Physicians, Inc.
 Moderator: Denise Levis Hewson, RN, BSN, MSPH
 Senior Vice President of Network Development and State Programs, CCNC
North Carolina’s Community
Health Centers
A Model of Patient Governed Integrated Health Care
Community Health Center Movement
• Movement grew out of 1960s Civil Rights
Movement and War on Poverty in an
effort to bring health services to
impoverished inner-city and rural
communities without access to care.
• First health centers established as pilots
through the Office of Economic
Opportunity in Boston, MA and Mound
Bayou, MS in 1965.
• Movement based on community-oriented primary
care, where community members accessed and
shaped the services delivered by their health
center.
• Health Center Program is now administered by
the Bureau of Primary Health Care in the Health
Resources and Services Administration.
12
Types of Health Centers
Grant-Supported Federally Qualified Health Centers are public and
private non-profit health care organizations that meet certain
criteria under the Medicare and Medicaid Programs and receive
funds under the Health Center Program (Section 330 of the Public
Health Service Act).
• Community Health Centers serve a variety of underserved
populations and areas.
• Migrant Health Centers serve migrant and seasonal agricultural
workers.
• Healthcare for the Homeless Programs reach out to homeless
individuals and families and provide primary care and substance
abuse services.
• Public Housing Primary Care Programs serve residents of public
housing and are located in or adjacent to the communities they serve.
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Other Types of Health Centers
• Federally Qualified Health Center Look-Alikes are health centers that have been identified by
HRSA and certified by the CMS as meeting the definition of “health center” under Section 330 of
the PHS Act, although they do not receive grant funding under Section 330.
• Outpatient health programs/facilities operated by tribal organizations (under the Indian SelfDetermination Act, P.L. 96-638) or urban Indian organizations (under the Indian Health Care
Improvement Act, P.L. 94-437).
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Health Center Program Fundamentals
• Located in or serve a high need community identified as having elevated
poverty, higher than average infant mortality, and where few physicians
practice.
• Governed by a community board composed of a majority (51% or more)
of health center patients who represent the population served.
• Provide comprehensive primary health care services as well as enabling
services (education, translation and transportation, etc.) that promote
access to health care.
• Provide services to all with fees adjusted based on ability to pay.
• Meet other performance and accountability requirements regarding
administrative, clinical, and financial operations.
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Health Center Program Requirements
1. Demonstrate & document need
2. Provide all required services and
additional services as necessary
3. Maintain core staff necessary for
services provided
4. Provide accessible hours of
operation/locations
5. Provide after-hours coverage
6. Have admitting privileges or other
arrangement to ensure continuity of
care
7. Implement sliding fee discounts
8. Have an ongoing Quality
Improvement/Quality Assurance
program
9. Maintain fully staffed management
team
10. Exercise oversight and authority over all
contracted services
11. Establish and maintain collaborative
relationships with other providers
12. Maintain financial management and
control policies
13. Implement systems to maximize
collections and reimbursement
14. Develop a budget to align with service
delivery plan
15. Have systems in place to collect and
organize data for program reporting
16. Maintain funded scope of project
17. Governing board maintains appropriate
authority to oversee operations
18. Maintain appropriate board composition
19. Enforce a strict conflict of interest policy
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Community Health Centers are Health Care
Homes
Health Center Required Services
• Comprehensive primary care
• Prenatal and perinatal services
• Family planning services
• Well child services
• Immunizations
• Cancer and other disease
screening
• Screening for blood lead levels,
communicable diseases and
cholesterol
• Preventive dental services
• Diagnostic lab and radiological
services
• Pharmacy
• Enabling services
• Eligibility workers
• Referrals
• Substance abuse and mental
health services
• Emergency medical and dental
services
• 24/7 access to care
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FQHC Integrated Services
2013 NC Health Center Centers
FQHC Look-Alike
Site Funded in CY2013
19
North Carolina’s Health Centers
Serving nearly 470,000 North Carolinians through:

35 Health Center Organizations

34 FQHCs

1 FQHC Look-Alike

1 Migrant Voucher Program

179 clinical service sites in 66 of 100 NC counties
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Goshen – Rosewood site
Blue Ridge Health Services
Roanoke Chowan Community Health Center –
Ahoskie Comprehensive Health Center
Snapshot of NC Health Center Staffing
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North Carolina’s Health Centers Serve
the Most Vulnerable Populations
NC CHC Patients vs. State Population
INCOME
LEVEL
<100% FPL
NC CHC Patients
NC Pop.21%
<200% FPL
INSURANCE
STATUS
RACE/
ETHNICITY
52%
25%
16%
Medicaid
Uninsured
48%
17%
Medicare
13%
15%
Private
14%
African…
22%
8%
Nearly 73% of NC
health center
patients have
Medicaid or no
insurance
51%
44%
White
Hispanic/L…
96%
42%
69%
33%
29%
CHC
96% of NC CHC
patients have
incomes below
200% of the
Federal Poverty
Level (FPL)
NC
NC Health Center
patients are more
racially/ethnically
diverse than the
overall state
population
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2013 National data Versus nc data
Other
Public
0%
Payer
Mix:
Other
Public
2%
Medicare
8%
Private
14%
Uninsured
35%
Medicaid
41%
Private
14%
Medicare
13%
Uninsured
48%
Medicaid
25%
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Considerations for FQHCs with ACO Design
• In many cases, FQHCs serve multiple communities and their delivery sites cross
county and regional areas.
• FQHCs depend upon hospital system and community partnerships in multiple locales.
• Delivery sites under the same FQHC umbrella fall in different ACO geographies. FQHC
tax ID numbers are the same for all providers regardless of delivery site, and some
providers serve at multiple sites.
• Exclusivity puts health centers in violation of federal regulations*. FQHCs must be
able to serve all Medicaid patients that present for care and Federal Section 330
funds cannot be used to underwrite Medicaid services
* Section 330 of the Public Health Service Act (42 USCS § 254b) Authorizing Legislation of the Health Center Program. 42 U.S.C § 254b(j)(3)(E-F)
Accountable Care Organizations Must Use Detailed
Cost Data to Risk-Adjust the Patient Population
• FQHCs serve a greater share of medically complex patients and
patients with social determinants (e.g., housing transportation,
language and education) that negatively impact their health.
• Risk adjustments must take into account detailed patient cost data
and social determinants of health factors to ensure the risk burden is
accurately calculated.
• ACO risk expectations should be predicated upon the health risk of
the population served because it is very difficult to achieve savings
among the highest cost patient population.